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Imaging Ultrasound Imaging for the Rheumatologist II. Ultrasonography of the Hand and Wrist

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Imaging Ultrasound Imaging for the Rheumatologist II. Ultrasonography of the Hand and Wrist Imaging Ultrasound imaging for the rheumatologist II. Ultrasonography of the hand and wrist E. Filippucci1, A. Iagnocco2, G. Meenagh3, L. Riente4, A. Delle Sedie4, S. Bombardieri4, G. Valesini2, W. Grassi1 1Cattedra di Reumatologia, Università ABSTRACT pathology of the hand and wrist could Politecnica delle Marche, Jesi, Italy; The hand is one of the anatomical be approached employing high quality 2Cattedra di Reumatologia, Università regions most frequently explored by real time imaging and a new field of Roma “La Sapienza”, Roma, Italy; ultrasonography (US) in rheumatology. research started. Since then, several 3Department of Rheumatology, Musgrave Park Hospital, Belfast, UK; The last generation US systems equip- studies have demonstrated the great 4Unità Operativa di Reumatologia, ped with high frequency probes allow value of US imaging of the hand and Università di Pisa, Pisa, Italy. for a quick and accurate assessment of wrist in rheumatology (4-16). Emilio Filippucci, MD; Annamaria even minimal pathological changes in This paper provides the basic knowl- Iagnocco, MD; Gary Meenagh, MD; patients with rheumatic conditions af- edge, reviews the available evidence Lucrezia Riente, MD; Andrea Delle Sedie, fecting the small joints and the soft tiss- and discusses the potential of US in the MD; Stefano Bombardieri, MD, Professor ues of the hand and wrist. Several stud- evaluation of the hand and wrist. of Rheumatology; Guido Valesini, MD, ies have demonstrated the great value Professor of Rheumatology; Walter Grassi, of US imaging of the hand and wrist in Indications MD, Professor of Rheumatology. rheumatology but there are still contro- There are several clinical settings in Please address correspondence and reprint versial issues which yet have to be ade- which US examination of the hand and requests to: Prof. Walter Grassi, Cattedra di Reumatologia, Università Politecnica quately addressed, particularly with re- wrist may be beneficial (Table I). In delle Marche, Ospedale “A. Murri”, Via gard to US semi-quantitative evalua- early arthritis hand US is a sensitive tool dei Colli 52, 60035 Jesi (AN), Italy. tion of synovitis and bone erosions in for detecting both synovitis and bone E-mail: [email protected] patients with chronic arthritis. This erosions in small joints (13-16). It can Clin Exp Rheumatol 2006; 24: 118-122. paper provides the basic knowledge, also carefully depict sub-clinical tendon Received and accepted on March 22, 2006 reviews the available evidence and dis- involvement in patients with chronic © Copyright CLINICAL AND EXPERIMEN- cusses the potential of US in the evalu- arthritis (17). US of the hand and wrist TAL RHEUMATOLOGY 2006. ation of the hand and wrist. is also of great use in the identification of underlying pathology responsible for Key words: Ultrasonography, hand Introduction clinical scenarios such as “sausage fin- and wrist, small joints, finger tendons, The hand is one of the anatomical ger” and “carpal tunnel syndrome” (18). median nerve. regions most frequently explored by The modality can therefore add vital ultrasound (US). This is for at least two information to tricky clinical situations main reasons. The first is related to the in rheumatological practice. fact that this area is a common target in several rheumatic diseases. The second Equipment is linked to the relatively wide acoustic The availability of a very high frequen- windows available for finger joints and cy probe is a ‘sine qua non’ for a com- tendons which permit careful depiction prehensive evaluation of the entire US of critical details for rheumatological landscape of the hand. The use of linear investigation. The hand is an anatomi- probes with frequencies > 10 MHz is cally complex region but in spite of this recommended. Another important fea- it should be regarded as a friendly area ture to consider is the size and the shape for the early training of rheumatolo- of the probe: small “hockey stick” gists in the difficult art of scanning transducers allow an easier multi-planar since many pathognomonic changes of assessment of the small joints of the several important rheumatic diseases hand because they can be readily placed can be depicted at this level. The earli- among the fingers. Wide footprint and est investigations in hand US date back extended view reconstructions allow to the late 1980’s with the availability panoramic views that are particularly of probes with frequencies > 10 MHz useful while assessing the anatomical (1-3). For the first time soft tissue structures of the wrist: radio-carpal and 118 Ultrasonography of the hand and wrist / E. Filippucci et al. IMAGING Table I. Main indications for performing an US examination of hand and/or wrist. lthy subjects, the thickness of the artic- ular cartilage of the metacarpal head Rheumatological setting Indications for performing US examination ranges from 0.2 to 0.5 mm (5). Early arthritis To reveal bone erosions, especially at II MCP joint level. In longitudinal scan, the triangular liga- To detect synovitis (especially sub-clinical joint inflammation). ment of the carpus appears as a homo- Tendon involvement To detect tendon inflammation (especially sub-clinical involvement). geneous echoic or hyper-echoic struc- To reveal tendon ruptures. ture between the head of the ulna and Dactylitis To characterize the underlying pathologic substrate (synovitis, tenosynovi- the triquetrum bone and is best seen tis, both synovitis and tenosynovitis, enthesitis). during abduction and adduction of the Carpal tunnel syndrome To visualize pathological conditions responsible for carpal tunnel syndrome. hand (20, 21). To depict morphostructural changes of the median nerve. Tendons Wrist pain To detect calcification or ruptures of the triangular ligament. Morphostructurally, the finger flexor US guidance for To reduce risk of damage due to needle contact or steroid injection. and extensor tendons appear on longi- injection therapy To visualize correct placement of drug during injection. tudinal scans, as tightly packed echoic Therapy monitoring To assess changes in soft tissue anatomy induced by therapy. bands with thin parallel linear echoes in patients with chronic (fibrillar pattern) separated by fine ane- arthritis choic lines. On transverse view, they have an oval-to-round shape and their inter-carpal joints, carpal tunnel and readily displaced even by minimal ex- echo-texture is characterised by tightly extensor tendon compartments. ternal pressure and result in underesti- packed echoic dots with a homoge- Power Doppler sonography (PDS) and mation of joint effusion. Moreover, for neous distribution (17, 22). colour Doppler sonography are now proper PD examination of a joint, the US examination of the tendons of the essential for assessment which also patient must be asked to take a position hand and wrist is relatively easy due to includes the study of tissue perfusion. generating the lowest intra-articular the absence of acoustic barriers and pressure. For the small joints of the their relatively straight course. Active Scanning technique hand, this position corresponds to the and passive movements of the fingers Each anatomical structure must be hand resting on the bed with a mild are very helpful when examining the explored through all the available degree of flexion of the joints. carpal tunnel or the IV compartment of acoustic windows using a multi-planar the wrist where more than four tendons scanning technique. In particular, the US anatomy lie next to one another. articular cartilage of the metacarpal Joints The flexor and extensor tendons of the head requires maximal flexion of the The articular surfaces of the small joints fingers are enveloped by a synovial metacarpophalangeal (MCP) joint to of the hand represent the landmarks to sheath for the majority of their course. expose the maximal extent of its sur- be visualised during US examination. A subtle anechoic layer, indicating syn- face to the US beam. US examination In all cases the bone profile appears as a ovial fluid surrounding tendons with of the II MCP joint must include evalu- sharp, continuous and hyperechoic line synovial sheath, can be visualized with ation of the lateral aspect of the joint generating an acoustic shadow. Particu- very-high frequency transducers (>13 where bone erosions, undetectable by lar attention should be paid during the MHz). The size of this virtual space for conventional antero-posterior hand evaluation of the anatomical neck of the the finger flexor tendons is 0.3 mm at radiography, are most frequently dis- metacarpal bone as it may be misinter- the level of the MCP joints. The ten- covered. preted as bone erosion. dons and their tracts with synovial The tendons must be assessed from In healthy subjects the joint space is sheaths are listed in Table II (17). Mild their musculo-tendinous origin to their filled by the intra-articular fat pad tendon sheath widening on the dorsal distal insertion into bone. Dynamic real which appears as an inverted triangular aspect of the IV compartment of the time examination is recommended for area with homogeneous echogenicity wrist, proximal to the extensor retinac- assessing the hand and wrist and is par- (19). ulum ligament is detectable in healthy ticularly true for the tendons and the Normal articular cartilage appears as a subjects. median nerve. Active and passive ten- homogeneous anechoic band delimited don movement during US examination by sharply defined hyperechoic mar- Median nerve can confirm the presence of a tendon gins. The superficial chondro-synovial At the entrance to the carpal tunnel the tear in cases where an intra-tendineous margin corresponds to the interface median nerve is located between the anechoic or hypoechoic area are found. between the synovial fluid and the car- tendon of flexor carpi radialis and the Both greyscale US and PDS mode re- tilage surface. This margin is thinner tendons of the flexor digitorum superfi- quire very low compression of the than the deeper one and its visualisa- cialis, deep to the tendon of palmaris probe on the tissues under examination.
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