Nuclear medicine in evaluation of the hand and wrist

Radionuclide evaluation of the hand and wrist is best performed with three-phase scintigraphy. This recent modification of the conventional bone scan includes a radionuclide angiogram to assess blood flow, as well as images that depict soft-tissue inflammation and areas of abnormal bone turnover. The clinical applications of three-phase scintigraphy include evaluation of patients with suspected vascular disorders, hand masses, infections, pain of uncertain etiology, and viability of composite tissue grafts.     

Accuracy of MRI-based Diagnoses for Distal Upper Extremity Soft Tissue Masses

To determine the accuracy of the pre-operative MRI-based diagnosis of soft tissue masses in the forearm, wrist, and hand, the records of 144 patients who underwent an MRI followed by excision of a soft tissue mass in the forearm, wrist, or hand were reviewed. The MRI-based diagnosis was compared to the histological diagnosis, which was considered the gold standard. The sensitivity, specificity, positive predictive value, and negative predictive value of the MRI-based diagnosis were calculated. A multivariate regression analysis was performed.While the accuracy of the MRI-based diagnosis varied widely, there was an overall sensitivity of 75 %. The most accurate diagnosis was an MRI-based diagnosis of ganglion cyst, which had a sensitivity of 94.7 % and a specificity of 94.4 %. Of particular concern was that the MRI-based diagnosis of a malignancy was only 66.7 % sensitive, with a positive predictive value of 44.4 %. On multivariate regression analysis, there was a trend towards improved accuracy in the wrist when compared to the finger, although this did not reach statistical significance.While pre-operative MRI remains a valuable tool for the evaluation of soft tissue masses in the distal upper extremity, caution is warranted when basing the diagnosis on MRI evidence alone.Level of Evidence: Level IV/Diagnostic     

MRI of wrist and hand masses

Hand and wrist masses represent a common diagnostic challenge. They are predominantly due to pseudomasses, which are mostly cysts and to benign masses that include tenosynovial tumors, fibrohamartolipomas, vascular malformations, glomus tumors and epidermal inclusion cysts. Malignant tumors of the wrist and the hand are extremely rare. Magnetic resonance imaging is the imaging technique of choice to characterize and circumscribe lesions to determine the best treatment option.     

Wrist joint ganglion presenting as a painless mass in the palm: report of 2 cases

Ganglions occur commonly in the wrist and arise from the radiocarpal and intercarpal joints. Although ganglions present commonly as masses on the dorsal or volar surface of the wrist, ganglions from wrist joints appear rarely at other locations in the hand. We report 2 cases of ganglions arising from wrist joints that presented as painless masses in the center of the palm without signs or symptoms of median or ulnar nerve compression. Surgical treatment required extensile exposure to trace the proximal stalks to their joints of origin. Knowledge of the possibility that a painless mass in the palm could be a ganglion arising from a joint in the wrist allows proper presurgical planning and informed consent.     

Venous aneurysms of the wrist

We describe 2 cases of primary atraumatic venous aneurysm affecting the wrist. Both aneurysms were in branches of the cephalic vein in close proximity to the radial artery. The definitive treatment for these venous aneurysms was surgical excision. There was no recurrence after 9 years in case 1 and after 11 years in case 2. Modern diagnostic modalities were used, including physical examination, Doppler ultrasonography, aspiration, magnetic resonance imaging, and venography. The pathologic analysis was consistent with those venous aneurysms reported in other parts of the body. The hand surgeon should be aware of this rare condition when formulating a differential diagnosis for soft tissue masses of the wrist.     

选择性利用游离皮瓣修复手、腕部软组织缺损

目的探讨多种游离皮瓣精细修复手、腕部软组织缺损的临床效果。方法针对手腕部软组织的缺损面积及形状等特点,对比分析皮瓣部位的质地、纹理,选取与手腕部相近似的5种游离皮瓣进行精细修复187例。修复方式：足底内侧动脉穿支皮瓣修复手掌及大鱼肌处软组织缺损49例．小腿后侧皮瓣修复全手掌侧软组织缺损46例,小腿外侧皮瓣修复手背软组织缺损42例,足背皮瓣修复手背软组织缺损伴伸肌腱缺损42例,髂腹股沟皮瓣修复手腕部软组织缺损8例。结果本组187例中185例皮瓣顺利成活,2例皮瓣远端少量坏死,经植皮后愈合。随访187例,随访时间6个月～3年,皮瓣质地良好,无明显臃肿,两点辨别觉6～9mm,手部经功能康复训练后,优96例,良71例。可20例,功能恢复满意。结论根据创面缺损形状与大小,选择不同游离皮瓣修复手、腕部软组织缺损,能达到精细修复目的．大大地提高了手功能。     

A case of bilateral extensor digitorum brevis manus

We report a case of symptomatic dorsal mass in a 72-year-old man, with onset of pain during daily life efforts. On the other side, the dominant hand, a similar mass without any impairment was present. Before surgery, the mass on the left nondominant wrist was diagnosed by ultrasound as synovial ganglion: during excision, a muscular belly was found and sent to isthological evaluation, confirming the existence of an alive aberrant muscular tissue, named Extensor Digitorum Brevis Manus. Being reported in literature as occasionally bilateral, we decided to perform, 3 months later, an MRI in the contralateral asymptomatic wrist: it was possible to reveal the presence of a similar but asymptomatic mass.     

Incidence of Extensor Digitorum Brevis Manus Muscle

The extensor digitorum brevis manus, a supernumerary muscle in the fourth extensor compartment of the dorsum of the wrist, is a relatively rare anomalous muscle. Extensor digitorum brevis should be included in the differential diagnosis of soft tissue masses on the dorsal aspect of the hand as it may mimic cystic, neoplastic, inflammatory, and infectious masses arising in the dorsum of the wrist. Seventy-two upper limbs of male and female cadavers were dissected and examined to study the pattern of extensor tendons of the index finger. In the present study, we observed three cases (4.2%) of the extensor digitorum brevis manus on the left side. In one cadaver (0.72%), there was an additional tendon arising from the extensor indices which was inserted to the radial side of the dorsal digital expansion of the index finger. The extensor digitorum brevis manus muscle (EDBM), an anatomic variant of the extensor muscle of the dorsum of the hand, is found in approximately 2% to 3% of the population. This variation is, therefore, clinically and surgically relevant because the EDBM may be the only muscle responsible for the independent extension of the second digit. The aim of the present study is to report the incidences of this muscle thereby creating awareness of its existence and of its characteristic appearance to surgeons.     

Carpal tunnel syndrome: a question of hand and wrist configurations?

This study investigated whether there is an association between hand and wrist configurations and the occurrence of carpal tunnel syndrome. The external hand and wrist dimensions of 50 subjects with carpal tunnel syndrome and 50 healthy volunteers were measured and compared. In addition carpal tunnel depth and width were determined with ultrasound. Our results showed that the hand length was significantly higher in the control group (hand length, 19.0; SD, 1.0 cm: patients' hand length, 18.2; SD, 1.1cm) and the palm width was significantly greater in the patients' group (palm width, 9.1; SD, 0.7 cm: controls palm width, 8.6; SD, 0.6 cm). Carpal tunnel syndrome patients had a squarer wrist (wrist ratio, 0.72; SD, 0.1) and carpal tunnel (carpal tunnel ratio, 0.48; SD, 0.1) than the controls (wrist ratio, 0.68; SD, 0.1; carpal tunnel ratio, 0.42; SD, 0.1). These findings indicate that the anatomy of the hand, wrist and carpal tunnel may predispose to carpal tunnel syndrome.     

Longitudinal observation of pediatric hand and wrist ganglia

The purpose of this study was to examine the behavior of ganglia of the hand and wrist in young children treated without surgery. Fourteen consecutive children, less than 10 years of age, who presented with cysts of the hand and wrist were followed up by a single surgeon. The average age of the patient at the time of diagnosis was 38 months (range, 2 months to 9 years 3 months). The masses included 7 retinacular cysts, 5 volar wrist ganglia, and 2 dorsal wrist ganglia. These cysts had been present for an average of 3.3 months (range, 1-12 months) before medical advice was sought. None of the cysts were painful. Follow-up averaged 33 months (range, 9-112 months), with 79% of all cysts spontaneously resolving, the majority within a year. We believe that a child presenting with a benign hand lesion characteristic of a ganglion cyst should initially be treated by observation.     

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

PURPOSE: Although several articles have described the sonographic features of solid and cystic lesions of the hand and wrist, few have investigated its accuracy for diagnosing such lesions. The purposes of this retrospective study were to determine the accuracy of sonography for diagnosing focal lesions of the hand and wrist against the standard of histologic examination of the resected specimen and to compare the accuracy of sonography against the recorded initial clinical impression. METHODS: A medical record search for all sonographic studies of the hand and wrist at our institution was performed. Eighty-four patients had correlative surgery and made up the study group. All sonogram reports were reviewed for the absence or presence of focal lesions and specific diagnoses and all medical records were reviewed for the initial clinical impression. Both were compared with histologic findings and tested for agreement with the kappa statistic and for significant differences with the McNemar test RESULTS: Seventy-six of the 84 patients had focal lesions of the hand and wrist and 8 had normal sonograms. Overall, ultrasound correctly diagnosed 83% of the lesions and the initial clinical impression was correct in 54%. Of the 76 lesions ultrasound correctly diagnosed 87% of cystic lesions, 73% of solid lesions, 75% of tenosynovitis cases and the single-vessel thrombosis. The initial clinical impression was correct in 67% of cystic lesions and 75% of tenosynovitis cases. The solid or cystic nature of the 15 solid lesions and the single-vessel thrombosis could not be determined by history or physical examination alone. Of the 35 cases in which the recorded clinical impression was incorrect or not recorded ultrasound provided the correct diagnoses in 71% of these cases. Agreement with the kappa statistical analysis was only fair and the recorded initial clinical impression was less accurate than ultrasound. CONCLUSIONS: Ultrasound was statistically more accurate than the initial clinical impression for distinguishing solid from cystic lesions of the hand and wrist. Ultrasound was very accurate for specifically diagnosing ganglions and slightly less for solid lesions and tenosynovitis.     

Work-related musculoskeletal disorders of the hand and wrist: epidemiology, pathophysiology, and sensorimotor changes

The purpose of this commentary is to present recent epidemiological findings regarding work-related musculoskeletal disorders (WMSDs) of the hand and wrist, and to summarize experimental evidence of underlying tissue pathophysiology and sensorimotor changes in WMSDs. Sixty-five percent of the 333 800 newly reported cases of occupational illness in 2001 were attributed to repeated trauma. WMSDs of the hand and wrist are associated with the longest absences from work and are, therefore, associated with greater lost productivity and wages than those of other anatomical regions. Selected epidemiological studies of hand/wrist WMSDs published since 1998 are reviewed and summarized. Results from selected animal studies concerning underlying tissue pathophysiology in response to repetitive movement or tissue loading are reviewed and summarized. To the extent possible, corroborating evidence in human studies for various tissue pathomechanisms suggested in animal models is presented. Repetitive, hand-intensive movements, alone or in combination with other physical, nonphysical, and nonoccupational risk factors, contribute to the development of hand/wrist WMSDs. Possible pathophysiological mechanisms of tissue injury include inflammation followed by repair and/or fibrotic scarring, peripheral nerve injury, and central nervous system reorganization. Clinicians should consider all of these pathomechanisms when examining and treating patients with hand/wrist WMSDs.     

Tumors and pseudotumors of the hand: The role of imaging

The assessment of a swelling or mass of the wrist or the hand is commonly performed by radiologists. Because cysts on the wrist are, by far, the most frequent pathology. Diagnosis is usually based on standard radiography and ultrasound alone. Additional imaging techniques, and in particular MR imaging, are necessary to assess tumors, although malignant tumors of the hand are rare. Some benign cysts have pathognomonic characteristics visible on imaging. By understanding them, treatment planning may be improved.     

Biopsy of hand, wrist, and forearm tumors

This article describes three biopsy methods currently used for treating masses arising in the hand, wrist, and forearm: open biopsy, fine needle aspiration, and core needle biopsy.The forearm, wrist, and hand comprise a complex and diverse anatomic region, and biopsy is emphasized as the most important element in the diagnosis of the musculoskeletal tumor. Biopsy methods for assessing true neoplasms, bony protuberances, cysts,infection and abscesses, foreign bodies, reactive granulomas, tenosynovial proliferation,and skin and fascial lesions are discussed.     

Traumatic false aneurysm of the radial artery

A patient was referred to the hand service for treatment of a ganglion of his left distal volar forearm. History and examination revealed the mass to be an aneurysm of the left radial artery. At surgery, a false aneurysm was resected and a vein graft interposed. This case illustrates arterial aneurysms, although uncommon, must be included in the differential diagnosis of masses about the hand and wrist.     

The hand in metastatic disease and acral manifestations of paraneoplastic syndromes

Metastatic tumors to the hand and wrist are rare, accounting for approximately 0.1% of all metastatic lesions to the skeleton. The biochemically mediated pathways of bone metastases, the location of the hand at the distal extremity, and the small amount of marrow in the bones of the hand and wrist account for the low prevalence of acrometastases. More rarely, hand dermatologic and soft tissue changes of paraneoplastic syndromes herald an occult malignancy.     

Ultrasound for the early diagnosis of clinically suspected scaphoid fracture

PURPOSE: To test the ability of ultrasound to diagnose clinically suspected occult scaphoid fractures. METHODS: Eighteen wrists in 18 patients with an average age of 35 years (range, 10-77 years) were seen in the emergency room, each with a single traumatic wrist injury, snuffbox tenderness, swelling, and a negative wrist x-ray result. They were evaluated in this prospective, blind, controlled study by physical examination, x-ray, and high-resolution ultrasound. One hand surgeon performed the examination, and ultrasounds were read by a musculoskeletal radiologist. Patients were immobilized in a thumb spica splint and then seen in the office 1 to 14 days after the emergency room visit, at which time a repeat physical examination, wrist x-ray, and the single investigative ultrasound were done using the opposite wrist as a control. All patients were immobilized and evaluated until symptoms resolved or x-ray showed scaphoid fracture site resorption or callus, in which case they were kept immobilized until healed. RESULTS: Ultrasound identified correctly 7 of 9 cases that were eventually positive for scaphoid fracture on plain x-ray. Ultrasound was read correctly as negative in 8 of 9 x-ray-negative cases; this was statistically significant. The 1 false-positive case had radioscaphoid arthrosis and radial wrist swelling. Sensitivity was 78% and specificity was 89%. The positive predictive value was 88% and negative predictive value was 80%. CONCLUSIONS: We recommend that high-frequency ultrasound be used to investigate occult suspected scaphoid fractures because of its ability to allow early diagnosis and to eliminate the need for a more invasive or expensive diagnostic test in most cases.     

Splinting of the hand and wrist

Splints have a variety of uses in the hand and wrist including the treatment of both soft tissue and bony injuries. They are the mainstay of treatment of many hand and wrist conditions. A sound understanding of the underlying anatomy and biomechanical principles is essential to ensure good practice. Risks associated with their use have been discussed to enable clinicians to appropriately prescribe, design and apply splints.     

桡动脉掌浅支腕横纹皮瓣微创修复手部软组织缺损

目的观察桡动脉掌浅支腕横纹皮瓣游离移植微创修复手部软组织缺损的临床疗效。方法应用微创显微外科技术切取桡动脉掌浅支腕横纹皮瓣修复28例手部软组织缺损患者,供区创面直接缝合。结果患者均获得随访,时间6~12个月。28例皮瓣全部存活,其中2例皮瓣出现边缘部分坏死,经换药处理伤口愈合。皮瓣色泽良好,外形美观,两点辨别觉为0.5~0.7 cm。供区线性瘢痕,无功能障碍。结论桡动脉掌浅支腕横纹皮瓣游离移植微创修复手部软组织缺损,手术简单,创伤小,皮瓣外形美观,功能良好。     

Correction to: A Clinical Approach to Diagnosing Trigger Wrist

BackgroundTrigger wrist is a relatively unusual condition, produced by wrist or finger motion. The various causes of trigger wrist can originate from flexor tendon, extensor tendon, bones, or tumour. A proper clinical approach is required to diagnose and manage patients with trigger wrist.MethodsA keyword search was performed across Google Scholar and PubMed. Articles describing trigger wrist conditions were analysed. Based on the information obtain from the articles, the clinical manifestations and approach to diagnosing the cause of trigger wrist is discussed.ResultsA detailed history alone may lead to a reasonably accurate diagnosis. Patients can present with trigger wrist occurring during movement of the fingers or with wrist movements. Presence of tenderness around A1 pulley suggest trigger finger. Absence of tenderness over the A1 pulley may suggest trigger wrist. The wrist should be examined for any swelling or malunion around the wrist joint. Palpate for any bony prominence, clicking, or crepitus with the movement of the wrist. Examination for the presence of carpal tunnel syndrome should be performed. A simple radiograph of the wrist joint is needed to see any possible bony pathology such as malunion, instability or arthritis of the carpal bone. For soft tissue assessment ultrasound would be a good choice and can be done during finger or wrist movement. MRI is useful for further assessment of space occupying lesion within the carpal tunnel and is useful for surgical planning. Nerve conduction study is indicated for patients with median nerve compression symptoms. During the initial stage, the patient should be advised for activity modification to reduce the wrist and finger movements. Surgical treatment will depend on the causative factor. Surgery done under local anaesthesia has the advantage of reconfirming with the patient, resolution of triggering during surgery by asking the patient to actively move the fingers or wrist. ConclusionsTrigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital.