Introduction to
Ultrasound Examination of
the Hand and upper
Ultrasound of upper ext.
Upside
¾ Convenient
¾ Opens another exam dimension
¾ Can be
Emil Dionysian, M.D.
like a “stethoscope”
stethoscope”
¾ Helps “3-D visualization”
visualization”
¾ Allows Dynamic , Functional exam
Up side
¾
¾
Immediate, and more
practical than MRI
Great patient pleaser
Intraoperative use
¾
¾
Available in OR
(Anesthesia work
room)
Loose body
Down side
¾
¾
New technology
Time: 55-10 min/pt. or
more
z
¾
Musculoskeletal Ultrasound
¾
¾
Less with more
experience
z
z
Learning curve:
z
z
z
Take a course
Pattern Recognition
But we are the ones
who know the
anatomy who else?
Special high
resolution transducer
Expense
¾
¾
¾
$30$30-80K
More functions more
money!
Room in the office
“The new fluroscan”
fluroscan”
Image Handling
1
Ultrasound in Upper extremity
Shoulder/arm
z
Elbow
¾
Rotator cuff pathology
¾
¾
z
Biceps distal and
proximal
¾
Triceps attachment
Collateral ligaments
Ulnar nerve location,
subluxation
Lateral and medial
muscle attachments
Triceps attachment
Lateral elbow
Lateral elbow
Medial elbow
2
Hand and wrist UTS evaluation
¾
¾
¾
Mass
Ligaments
Tendon:
z
z
z
¾
¾
Mass in the palm
Location
Subluxation
Rupture
Foreign Bodies
Vessel:
z
z
Size
Location
Thumb MP Ligaments
UCL tear detection
¾ Journal
Radiology May 2010
¾ M.Nozian,et al
¾ 69 UCL tear suspected and had US
¾ 43 had surgery
¾ 37 out of 43 had correct dx.
¾ 6 false positive
¾
Lee J C , Healy J C
Radiographics
2005;25:1577-1590
Figure 1b. Normal sonographic appearance of tendons in the wrist.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 1a. Normal sonographic appearance of tendons in the wrist.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
3
Transverse sonogram through the anatomic snuffbox shows the tendons of the first
extensor compartment: the extensor pollicis brevis (EPB) and the abductor pollicis longus
(APL).
Volar Wrist Ganglion and the artery
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Transverse sonogram shows the second extensor compartment, which contains the
extensor carpi radialis brevis (ECRB) and longus (ECRL) tendons.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Anisotropy artifact.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Transverse sonogram shows the extensor surface of the wrist at the level of the distal carpal
row, with a normal small volume of anechoic synovial fluid in the tendon sheath between the
extensor tendons.
Figure 4a. Normal sonographic appearance of nerves.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
4
Normal sonographic appearance of nerves.
Carpal Tunnel
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Transverse sonogram shows the third extensor compartment, which contains the extensor
pollicis longus (EPL) tendon, and its location between the neighboring extensor digitorum
(ED) and extensor carpi radialis brevis (ECRB) tendons.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 9. Transverse sonogram shows the third through the fifth extensor compartments.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 8. Transverse sonogram shows the fourth extensor compartment.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Transverse sonogram shows the sixth extensor compartment, which contains the extensor
carpi ulnaris (ECU) tendon and sheath.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
5
ECU motion with supination
ECU subluxation
¾
Ulnar artery
pronation
neutral
supination
Transverse sonogram shows the dorsal aspect of the proximal carpal row, just distal to the
level of the Lister tubercle.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 12. Transverse sonogram at the same level as Figure 11 but on the ulnar side of the
dorsal carpus shows the echogenic dorsal aspect of the lunatotriquetral ligament and, above
it, the extensor digiti minimi (EDM) tendon.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 13a. Sonographic examination of the ulnar surface of the wrist.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
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Figure 13b. Sonographic examination of the ulnar surface of the wrist.
Wrist ligament and TFC tears
¾ Skeletal radiology 2003
¾ Finlay,K. et al from Canada
¾ 26 pt. with
wrist pain with tri comp. arthrog
¾ 10/10 SS-L lig tear US and Arthorgram
¾ 2/8 lunotriq. and 7/10 TFC tears on UTS
¾ Intermediate accuracy for TFC tears
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Sonographic appearance of the dorsal extensor hood of the finger.
Figure 15b. Sonographic appearance of the dorsal extensor hood of the finger.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Sonographic appearance of the dorsal extensor hood of the finger.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
©2005 by Radiological Society of North America
Normal sonographic appearances of the carpal tunnel.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
7
Normal sonographic appearances of the carpal tunnel.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 17. Transverse sonogram of the carpal tunnel shows the location of the flexor carpi
radialis (FCR) tendon within the lateral part of the flexor retinaculum.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 18b. Sonographic appearance of the long flexor tendons in the palm.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 18a. Sonographic appearance of the long flexor tendons in the palm.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 19a. Sonographic appearances of the long tendons of the finger, the flexor digitorum
superficialis (FDS) and flexor digitorum profundus (FDP).
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
8
Figure 19b. Sonographic appearances of the long tendons of the finger, the flexor digitorum
superficialis (FDS) and flexor digitorum profundus (FDP).
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 20. Longitudinal sonogram shows the insertion site of the flexor digitorum
superficialis tendon at the base of the middle phalanx.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
FPL over prox. phalanx
Figure 19c. Sonographic appearances of the long tendons of the finger, the flexor digitorum
superficialis (FDS) and flexor digitorum profundus (FDP).
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 21a. (a) Longitudinal sonogram shows the insertion of the flexor digitorum profundus
(FDP) tendon onto the base of the terminal phalanx.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 21b. (a) Longitudinal sonogram shows the insertion of the flexor digitorum profundus
(FDP) tendon onto the base of the terminal phalanx.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
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FDP and FDS at MP
FPL repair 4 wks
¾
Repair side
FDP intact / laceration
¾ Intact
¾
Normal contralateral
FDP at PIP level
intact
¾ missing
missing
Digital Annular Pulley
Figure 22a. Transverse (a) and longitudinal (b) sonograms through the thenar eminence
show the relationship of the echogenic flexor pollicis longus tendon to the short muscles of
the thumb.
¾ Skeletal radiology 2000
¾ Martinoli,C. et al
¾ US detected 8/9 DAP rupture
¾ Indirect sign of volar bowstringing
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
10
Figure 22b. Transverse (a) and longitudinal (b) sonograms through the thenar eminence
show the relationship of the echogenic flexor pollicis longus tendon to the short muscles of
the thumb.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 24. Transverse sonogram at the level of the proximal part of the proximal phalanx
shows the second annular pulley as a hypoechoic thickening of the flexor sheath that
extends to the sides of the base of the proximal phalanx.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 23. Transverse sonogram of the Guyon canal, obtained by using the linear-array
transducer in sector mode for a wider field of view, shows the presence of a normal variant
accessory muscle that may be associated with compression of the adjacent ulnar nerve.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 25. Longitudinal sonogram of the finger at the level of the proximal phalanx shows the
second annular pulley as a thin hyperechoic line (arrows) superficial to the long flexor
tendons.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
Figure 26. Transverse sonogram of the finger at the level of the head of the middle phalanx
shows the fifth annular pulley, which covers the flexor digitorum profundus (FDP) tendon at a
point just proximal to the distal interphalangeal joint, as well as several vessels in a location
superficial to the pulley.
Lee J C , Healy J C Radiographics 2005;25:1577-1590
©2005 by Radiological Society of North America
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