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Ultrasound examination of the wrist joint
Dr ABD ALLAH NAZEER MD
ULTRASOUND OF THE WRIST ndash Normal
Dorsal Wrist Compartments
Compartment 1 scan plane
Compartment 2 Scan planeExtensor Carpi Radialis Longus and Brevis
Transverse view of the extensor carpi radialis longus and brevis tendons
Scapho lunate ligament scan plane
Scapho-lunate ligament is seen as a fibrillar tight band Visualizing the SCL does not exclude carpal instability
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
ULTRASOUND OF THE WRIST ndash Normal
Dorsal Wrist Compartments
Compartment 1 scan plane
Compartment 2 Scan planeExtensor Carpi Radialis Longus and Brevis
Transverse view of the extensor carpi radialis longus and brevis tendons
Scapho lunate ligament scan plane
Scapho-lunate ligament is seen as a fibrillar tight band Visualizing the SCL does not exclude carpal instability
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Compartment 1 scan plane
Compartment 2 Scan planeExtensor Carpi Radialis Longus and Brevis
Transverse view of the extensor carpi radialis longus and brevis tendons
Scapho lunate ligament scan plane
Scapho-lunate ligament is seen as a fibrillar tight band Visualizing the SCL does not exclude carpal instability
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Compartment 2 Scan planeExtensor Carpi Radialis Longus and Brevis
Transverse view of the extensor carpi radialis longus and brevis tendons
Scapho lunate ligament scan plane
Scapho-lunate ligament is seen as a fibrillar tight band Visualizing the SCL does not exclude carpal instability
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Scapho lunate ligament scan plane
Scapho-lunate ligament is seen as a fibrillar tight band Visualizing the SCL does not exclude carpal instability
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Compartment 3 scan planeExtensor Pollicis Longus
The EPL tendon is tucked against Listers Tubercle The Extensor digitorum longus common tendon is adjacent in compartment 4
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Compartment 4 Scan plane
Extensor digitorumThe common extensor digitorum tendon divides into 4 prior to the wrist crease
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Common extensor Digitorum with the overlying extensor retinaculum
Compartment 5 Extensor digiti minimi immediately medial to the extensor digitorums
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Compartment 6 Scan planeExtensor Carpi Ulnaris Extensor carpi ulnaris
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
ANTERIOR WRIST
A basic schematic of the anterior wrist tendons and Carpal Tunnel
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Scan plane for the carpal tunnel
Transverse carpal tunnel Flexor carpi radialis (FCR) Flexor Pollicis Longus (FPL) Median Nerve (MN) Flexor Digitorums
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Scan plane for the FCR tendonThe flexor carpi radialis tendon curving over the
scaphoid to insert onto the 1-2 metacarpal bases
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Scan plane for the FCU tendon The Flexor Carpi Ulnaris tendon
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Indication for wrist ultrasound study
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
ROLE OF ULTRASOUNDUltrasound is a valuable diagnostic tool in assessing the following indications in the wristMuscular tendinous and ligamentous damage (chronic and acute)BursitisJoint effusionVascular pathologyHaematomasSoft tissue masses such as ganglia lipomasClassification of a mass eg solid cystic mixedPost surgical complications eg abscess edemaGuidance of injection aspiration or biopsyRelationship of normal anatomy and pathology to each otherSome bony pathology
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
LIMITATIONSRecent surgery or injections may degrade image quality through the presence of air in the tissueEQUIPMENT SELECTIONUse of a high resolution probe (10-15MHZ) is essential when assessing the superficial structures of the wristCareful scanning technique to avoid anisotropy (and possible misdiagnosis)Beam steering or compounding can help to overcome anisotropy in linear structures such as tendonsGood colour power Doppler capabilities when assessing vessels or vascularity of a structureBe prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
The posterior wrist is conveniently divided into 6 compartmentsAbductor pollicis longus(APL) and Extensor Pollicis Brevis (EPB)Extensor Carpi Radialis (ECR) longus and BrevisExtensor Pollicis Longus (EPL)Extensor Digitorum (ED)Extensor Digiti Minimi (EDM)Extensor Carpi Ulnaris (ECU)These are all tethered by the extensor retinaculum which overlies and in some areas reflects around the tendonsBegin by scanning over the lateral wrist crease at the anatomical snuff-box You should see the APL amp EPB in compartment 1 To check both tendons should be able to be followed up the thumb If they go to the carpus you have slipped medially onto compartment 2 Work your way sequentially across the wrist assessing each tendon individuallyDe Quervains tenosynovitisInflammation of the Abductor Pollicis Longus and Extensor pollicis Brevis tendonsOveruse injuryPatients present with focal point tenderness laterally over the radial styloid
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Proximal intersection syndromeExtensor Pollicis Brevis crossing over extensor Carpi Radialis longus amp BrevisDistal intersection syndromeExt Pollicis Longus crossing over extensor Carpi Radialis longus amp BrevisScapho-lunate ligamentThe wrist is essentially divided into 3 joint planes1 and 2 The radiocarpal and midcarpal Joints allow wrist flexion extension and lateral deviation3 The distal radio-ulnar joint allows the forearm and hand to rotate (Pronation Supination)These joints are supported by a series of extrinsic and intrinsic ligaments The scapholunate ligament is the most important dorsal intrinsic stabilizerInjury occurs with a hyperextension of the wrist Similar mechanism to a scaphoid fracture but results in a ligament tear insteadIf only a partial tear it is usually stableIf complete it results in Scapho-lunate instability The scaphoid will rotate abnormally during wrist movement which if left untreated can lead to significant chronic wrist degeneration
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
ANTERIOR WRIST
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal Tunnel SyndromeThis is the most common peripheral nerve entrapment It occurs when the median nerve is compressed by the overlying flexor retinaculumIMPORTANTUltrasound cannot exclude Carpal tunnel syndrome The accepted standard for diagnosis is a nerve conduction studyOur role is to identify possible causes for the patients symptomsLook forTendon abnormalitiesGangliaFluidAccessory musclesAny asymmetry with the contra lateral sideThere have been several proposed methods of quantitative assessment for carpal tunnel In our experience these have not been reliable They includeNerve cross sectional area of gt10square mm proximal to the retinaculumNerve flattening ratio of 31
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Guyons Canal SyndromeCanal bordered by the pisiform amp hamate and roofed by a reflection of the flexor retinaculum The ulna nerve and artery pass through and may become entrapped or injured Repetitive injury such as cycling or using heel of hand as hammerOn Ultrasound As with carpal tunnel look for ganglia accessory muscles and asymmetry with the contra lateral side
Triangular Fibro-Cartilage Complex (TFCC)A section of cartilage and ligaments at the distal ulnaProvides a continuous gliding surface along the forearm-carpal jointAffected byNatural degeneration with age
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Detection of Effusion in the volar recess of the PIP joint ndash longitudinal and transverse views
A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint There is normally only a small physiological amount of fluid Abnormal fluid accumulation can result from inflammation infection (ie pus) or trauma and may be an exudate transudate blood andor fat
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Effusion noted on longitudinal view over the radiocarpal joint
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
TFCC tears can be degenerative and occur after the third decade They are usually asymptomatic and have to be differentiated from traumatic tears Palmerrsquos classification aims to classifying the kind and location of tear Central tears (type IA) are common and are located at the horizontal portion of the articular disk just 2 to 3 mm from the radial origin Ulnar tears (type IB) are less common but may lead to DRUJ instability if they are not diagnosed at an early stage Recent studies have described new entities such as lsquobucket-handlersquo tears or association between different types of tears
Ultrasound allows a partial visualization of the TFCC because the size of the acoustic window varies with the size and the morphology of the ulnar styloid and the ulnar variance Articular disk assessment may be limited if there is a positive ulnar variance or if the ulnar styloid is hypertrophic According to recent studies sensitivity ranged from 63 to 100 whereas specificity was 100 Nevertheless it is not possible to distinguish degenerative tears from traumatic ones and the location of tears has not been described in those studies For these reasons ultrasound is not the modality of choice in order to assess TFCC integrity CT may show indirect sign of TFCC injuries if DRUJ dislocation is present
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Central and peripheral TFC disk tears Coronal T1W MRA image of the wrist with fat suppression (A) and longitudinal sonoarthrogram of the TFC disk (B) in the same patient show a central TFC disk tear (arrow) Note the leak of radiocarpal joint contrast into the distal radioulnar joint in A and the leak of radiocarpal joint contrast through the ulnar joint capsule into the adjacent soft tissues through the peripheral TFC complex tear in A and B (arrowheads)
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Triangular fibrocartilage disk tear On all images the distal ulna is on the left and the triquetrum is on the right A Longitudinal sonogram shows a hypoechoic appearance of the central aspect of the TFC disk consistent with a tear (arrows) B Longitudinal sonogram in a different patient shows an area of abnormal hypoechogenicity at the periphery of the TFC disk (arrow) under the ECU consistent with a peripheral tear C Longitudinal sonoarthrogram in the same patient as in B improves visualization of the peripheral TFC disk tear and shows extension of intra-articular contrast in an additional TFC disk clefttear (arrow)
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Ganglion cysts are non-malignant cystic masses that occur in association with
musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion
UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement
Dorsal Ganglion cyst
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Wrist Ganglion
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Wrist Ganglion
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Ultrasound in axial plane shows torn (a) and normal fibrillar appearance (b) of the scapholunate ligament
SCAPHOLUNATE LIGAMENT TEARSThe scapholunate (SL) ligament is an intrinsic ligament between the scaphoid and lunate with three bundlesDorsal and ventral bundles are composed of collagen fibers The dorsal one is thicker and plays a major role in wrist stabilityCentral (or proximal) bundle is fibrocartilaginous and may present degenerative and asymptomatic changes in elderly patients
Ultrasound is a widely available technique and is useful to assess the SL ligament The visibility of the ligament varies from 91 to 98 due to its superficial location The dorsal segment is superficial and can be easily assessed just distally to the Listerrsquos tubercle
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Scapholunate ligament tear
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome (CTS) is results from compression of the
median nerve within the carpal tunnel It is a cause of significant disability and is one of three common median nerve entrapment syndromes the other two being anterior interosseous nerve syndrome and pronator teres syndrome
UltrasoundIn imaging median nerve syndromes ultrasound is useful in examining CTS potentially revealing in fully developed cases a triad ofpalmar bowing of the flexor retinaculum (gt2 mm beyond a line connecting the pisiform and the scaphoid)distal flattening of the nerveenlargement of the nerve proximal to the flexor retinaculumEnlargement of the nerve seems to be the most sensitive and specific criterion but what cut-off value for pathological size remains debated normal cross-sectional area is given at 9-11 mm but the range of sizes deemed pathological is wide One study has calculated that a 2 mm difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99 sensitivity and 100 specificity for CTS
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome with thickened median nerve
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome in bifid median nerve
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome with inverted notch sign
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
A 36-year-old male with symptoms of CTS Transverse USG shows scar tissue (arrow) at the site of decompression
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
CTS Longitudinal USG shows proximal synovial bulge (arrow) with hypoechoic exudative tenosynovitis
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
CTS Transverse USG shows scar tissue at the site of surgery (arrow) and incomplete division of the flexor retinaculum (arrowheads)
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome Transverse sonogram showing reformed flexor retinaculum (pink arrow) and flattened median nerve (blue arrow)
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
CTS Transverse USG shows reformed flexor retinaculum (arrow) median nerve (arrow head) and the muscle belly of the flexor digitorum profundus (star)
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Carpal tunnel syndrome Transverse sonogram showing neurogenic tumor at the carpal tunnel
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Guyons Canal SyndromeYour wrist has tunnels or canals through which some nerves and blood vessels pass Guyons canal is located along the lower edge of your palm on the little finger side of your hand Your ulnar nerve and artery run through this canal where the nerve splits into two terminal branches that go on into your palm ring and little fingers Compression or entrapment of the ulnar nerve at the canal leads to pain tingling and numbness in the left side of your palm and in your ring and little fingers
CAUSES The disorder is caused by pressure on the ulnar nerve This is most likely the result of external pressures (handlebars on a bike) but may also be internal (tumor cyst fracture or aneurysm of the ulnar nerve)
RISK INCREASES WITHDiabetes mellitusUnderactive thyroid gland (hypothyroidism)MenopauseRaynauds disease (vascular disorder)Long-distance cyclingRepeated jolting or shaking of the hands or wristGoutSports that may cause fracture of the hamate bone in the hand (baseball batting golf tennis badminton)Rheumatoid arthritisGanglion cystCarpal tunnel syndrome
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Guyons Canal Syndrome secondary to space occupying lesion
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Ulnar nerve irritation at the Guyons canal
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Tenosynovitis is a term describing the inflammation of the synovial membrane surrounding a tendon The synovial membrane is part of a fluid-filled sheath that surrounds a tendon EtiologyTenosynovitis can be caused by a variety of disease processes including but not limited toinjuryrheumatic diseaseinfectionmechanical irritationcompartment syndromegoutpseudo gout CPPDdiabetesUltrasoundOn ultrasound the synovial membrane is not identified unless there is pathological swelling We can find increased fluid content within tendon sheath a thickening of the synovial sheath peritendinous subcutaneous edema resulting in a hypoechoic halo sign and peritendinous subcutaneous hyperemia on Doppler imaging
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Active synovitis overlying a large metacarpal head erosion
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Longitudinal view of the wrist revealing active synovitis
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Crystalline arthropathy Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Acute tenosynovitis of common extensor tendon of wrist
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Acute inflammation of common extensor tendon of hand Transverse image showed thickening and decrease the echogenicity (arrows) in the tendon sheath with hypervascularity in CDUS This is acute tenosynovitis case MC metacarpal bones
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Tenosynovitis of 6th compartment (extensor carpi ulnaris tendon) (arrows) US image showed thickening of tendon sheath (arrows)
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Septic arthritis and tuberculous arthropathy is one of the common cause of infectious arthritis is developing countries Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise Risk factors for septic arthritis include bacteraemia advanced age an immunocompromised state rheumatoid arthritis intraarticular injections and prosthetic jointsUltrasoundJoint effusion may be the only finding but is non-specific
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Hand and wrist abscesses
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
TB granuloma 2 2nd metacarpal bone 3 3rd metacarpal bone
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
De Quervain tenosynovitis also known as washerwomans sprainstrain is a painful stenosing tenosynovitis involving the first extensor (dorsal) tendon compartment of the wrist (typically at the radial styloid) This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
UltrasoundUltrasound is very often diagnostic Findings include oedematous tendon thickening of APL and EPB at level of radial styloid (compare with contralateral side) increased fluid within the first extensor tendon compartment tendon sheath thickening of overlying retinaculum and the synovial sheathperitendinous subcutaneous edema resulting in a hypoechoic halo sign peritendinous subcutaneous hyperemia on Doppler imagingIt is important to assess for an intratendinous septum which can usually be identified if present Ultrasound is often used to guide corticosteroid injections into the tendon compartment to treat the condition
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
De Quervains syndrome Transverse section of APL and EPB tendons showed thickening tendon sheath over EPB tendon and CDUS showed hypervascularity Tenosynovitis of EPB is considered APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
De Quervainrsquos tenosynovitis Transverse section of APL and EPB tendons showed thickening tendon sheath (arrows) over the common tendon of EPB and APL CDUS showed hypervascularity APL abductor pollicis longus tendon EPB extensor pollicis brevis tendon
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Extensor tendon rupture
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Foreign body
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Giant cell tumours of the tendon sheath (GCTTS) is an uncommon and usually benign lesion that arises from the tendon sheath It is unclear whether these lesions represent neoplasms or simply reactive masses It is also known as pigmented villonodular tumour of the tendon sheath (PVNTS) or extra-articular pigmented villonodular tumor of the tendon sheath UltrasoundUltrasound is useful as it allows not only characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon On dynamic scan there is free movement of the tendon within the lesionThese masses are typically homogeneously hypoechoic although some heterogeneity may be seen in echo-texture in a minority of cases Most will have some internal vascularity
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Giant cell tumor of wrist
Giant cell tumor of metacarpal
Thank You
Giant cell tumor of metacarpal
Thank You
Thank You
![Ultrasound -WC 2017-KW.pptx [Read-Only]€¦ · Joint‐Elbow effusion, wrist ganglion cyst ... Microsoft PowerPoint - Ultrasound -WC 2017-KW.pptx [Read-Only] Author: akeeney Created](https://img.dokumen.tips/doc/110x75/5ac89e287f8b9aa3298c441e/ultrasound-wc-2017-kwpptx-read-only-jointelbow-effusion-wrist-ganglion.jpg)
