Enhanced MR imaging of tenosynovitis of hand and wrist in inflammatory arthritis

Objective The purpose of this study is to describe the appearance of tenosynovitis in various tendon groups in the wrist and hand and to compare MR enhanced and non-enhanced imaging evaluation of tenosynovitis of hand and wrist in inflammatory arthritis.Design and patients We reviewed 72 MRI studies of hands and wrists, including coronal, axial and sagittal images in 30 consecutive patients with inflammatory arthritis and tenosynovitis. We compared the degree of synovitis on T2-weighted vs contrast-enhanced T1-weighted images, using a predetermined scale. We also measured the extent of tenosynovitis in three dimensions. The tendons were assigned to volar, dorsal, ulnar and radial groups in the wrist and to extensor, flexor and thumb groups in the hand. Degree of tenosynovitis (graded 0–3), cross-sectional area and volume of the inflamed synovium in various tendon groups were then compared by statistical analysis.Results Review of the medical records revealed the following diagnoses in our patient population: rheumatoid arthritis (n=16), unspecified inflammatory polyarthritis (n=9), psoriatic arthritis (n=2), CREST syndrome (n=1), systemic lupus erythematosus (n=1), paraneoplastic syndrome with arthritis (n=1). The average T2 brightness scores and post-gadolinium enhancement scores were 1.0 and 1.7, respectively (P<0.001) in the wrist studies. The average T2 brightness scores and post-gadolinium enhancement scores were 0.7 and 1.4, respectively (P<0.001) in the hand studies. The average sensitivity of T2-weighted imaging for detection of tenosynovitis was 40% in the hand and 67% in the wrist tendons, when contrast-enhanced images were used as a reference. Carpal tunnel flexor tendons were the most frequently affected tendons of the wrist. The most frequently affected tendons of the hand were second and third flexor tendons. The hand flexors demonstrated higher degrees of enhancement and larger volumes of the inflamed tenosynovium than did the hand extensors and tendons of the thumb.Conclusion Enhanced MR imaging of the hand and wrist is a superior technique for detection of tenosynovitis. We observed carpal tunnel flexor tendons to be the most frequently affected tendons of the wrist. The flexor tendons of the second and third digits were the most frequently affected tendons of the hands. Higher contrast-enhancement scores and inflammation were noted in the hand flexor than in the extensor tendons.     

Dynamic MR imaging of carpal tunnel syndrome

 Objective. To evaluate the diagnostic value of the MR imaging syndrome before and after performance of provocative exercises in patients with dynamic carpal tunnel syndrome. Design. Fat-suppressed proton-density and T2-weighted spin-echo images of the wrist were obtained prior to and after provocative, standardized exercises. Images were interpreted in masked fashion with regard to six MR criteria of carpal tunnel syndrome: (a) bowing of the transverse ligament, (b) and (c) deformation of the median nerve at the pisiform and hamate levels respectively, (d) signal abnormality of the median nerve, (e) presence of fluid in the wrist joints and/or carpal tunnel, and (f) presence of synovial swelling. Patients. Twenty-one wrists in 20 patients with subjective complaints of carpal tunnel syndrome and equivocal or negative clinical findings and negative electrodiagnostic examinations were included (age range 21–61 years, mean 37 years, 2 men and 18 women). The diagnosis of dynamic carpal tunnel syndrome was made and confirmed by surgery in 18 of the 21 symptomatic wrists. The control group consisted of 15 asymptomatic wrists in volunteers (age range 22–60 years, mean 35 years, 8 men and 7 women). Results and conclusions. Sensitivities and specificities of the six MR criteria were 90.5–100%, and 6.7–86.7%, respectively, both before and after exercise. Likelihood ratios proved statistically significant differences between the symptomatic and asymptomatic wrists (P<0.0001–0.0002) for the prevalence of all MR criteria with the exception of fluid within the carpal joints and/or carpal tunnel. Changes of the MR appearance after exercise had a low sensitivity (4.8–71.4%) but high specificity (86.7–100%) for dynamic carpal tunnel syndrome. In conclusion, MR imaging contributes to the diagnosis of carpal tunnel syndrome when clinical signs are confusing and electrodiagnostic studies are negative. Dynamic examinations improve specificity of MR imaging for such diagnosis.     

Diagnostic imaging of tumors of the hand and wrist

Tumors of the hand and wrist most commonly result from dystrophic lesions and hamartomas. Neoplastic lesions are rare. Imaging modalities are required for their detection and accurate location, careful assessment of the internal structure and borders, evaluation of the relation with surrounding tendons, nerves, and vessels, and are also required for staging. A variety of imaging techniques, including standard radiographs, sonography, CT, and MRI, can be obtained. The aim of this article is to present paradigmatic images of a variety of expansible lesions of the hand and wrist and to describe and compare the diagnostic findings of different imaging techniques.     

MRI features in de Quervain’s tenosynovitis of the wrist

 De Quervain’s stenosing tenosynovitis of the first dorsal extensor component is traditionally diagnosed clinically but may be encountered when performing MRI of the wrist. A retrospective review of wrist MR images was performed in cases where the diagnosis of de Quervain’s synovitis was sugggested (n=5). Imaging findings were correlated with clinical findings in four cases and with wrist arthroscopy in one case. Increased thickness of the extensor pollicus brevis and abductor pollicis longus tendons was the most reliable finding on MRI, being present in all cases. Peritendinous edema was also a reliable finding. Surrounding subcutaneous edema and increased intratendinous signal were less reliable findings in confirmed cases of de Quervain’s disease. De Quervain’s tenosynovitis may be encountered when performing MRI of the wrist. Increased tendon thickness and peritendinous edema are the most reliable imaging findings.     

Ultrasound imaging of non-traumatic lesions of wrist and hand tendons

Non-traumatic tendon lesions are common and diverse at the wrist and hand. Improvements in high-resolution ultrasound (US) are producing increasingly high-quality images of superficial structures, thus expanding the indications for this imaging modality as a tool for investigating musculoskeletal disorders. The objective of this work is to provide an update on the uses and performance of US in non-traumatic tendon disorders of the wrist and hand. The relevant anatomy is reviewed, and the normal and abnormal ultrasound scan features are described in detail, with attention not only to the tendons but also to closely related structures such as synovial sheaths and bands. The contribution of US to the evaluation of each of the most common disorders is discussed.     

Technical advances in ultrasound and MR imaging of carpal tunnel syndrome

The aim of this study was to compare the latest ultrasound-array technology to a conventional “high-resolution” transducer, modified MRI technique, and nerve conduction studies (NCS), in the diagnosis of carpal tunnel syndrome (CTS). In 19 normal wrists and 15 wrists with CTS, US with two different transducers was performed: a conventional linear-array transducer (LA) and a newly developed Multi-D linear-array transducer (MDA) were used. The US images were evaluated determining the swelling and the flattening ratios of the median nerve and correlated to respective findings in MRI (1.5 T) and to NCS. The NCS confirmed CTS in all 15 wrists. Measures of median nerve compression (swelling and flattening ratios) were significantly different in patients with CTS and controls (p < 0.01) with both types of US transducers and MRI. The MDA yielded higher correlation to MRI than the LA. Using critical values of 1.3 for the swelling and 3.4 for the flattening ratio, MRI, and US with the MDA yielded a sensitivity of 100 % each. Modern imaging modalities allow for an exact diagnosis of CTS even in cases with only slight median nerve pathology. Received: 24 June 1999; Revised: 8 October 1999; Accepted: 25 February 2000     

Indirect wrist MR arthrography: the effects of passive motion versus active exercise

Purpose.In the wrist, to determine whether passive motion or active exercise yields a better indirect MR arthrographic effect following intravenous gadolinium administration. Design and patients. Twenty-six consecutive patients were studied by indirect wrist MR arthrography. In half active exercise and in half passive motion was performed. Four regions of interest were studied including the distal radioulnar joint, the radiocarpal joint, the midcarpal joint, and the triangular fibrocartilage. Ranges and means of signal intensity were calculated. Surgical follow-up was performed in 22 patients. Results. The joint fluid intensity was greatest in the distal radioulnar joint. Fluid signal intensity was greater and more consistent in the passive motion group although the results did not achieve statistical significance. Imaging accuracy appeared similar in the two groups and was excellent for the triangular fibrocartilage (100%) and scapholunate ligaments (96%). Conclusion. Active exercise and passive motion yield similar degrees of wrist arthrographic effect, but the effect of passive motion is somewhat more consistent. Preliminary data show good accuracy for internal derangements. Received: 4 June 1999 Revision requested: 6 August 1999 Revision received: 14 September 1999 Accepted: 20 September 1999     

MR imaging of ulnar nerve entrapment secondary to an anomalous wrist muscle

MR imaging of an anomalous hypothenar adductor muscle causing isolated deep ulnar nerve branch compression and producing a purely motor neuropathy is presented. The muscle appears to represent a type 1 variant of the intrinsic anomalous hypothenar adductor muscle.     

Hook of the hamate fracture not visualized by standard wrist or classic carpal tunnel projections

After trauma to the wrist, hook of the hamate fracture may not be visualized by standard plain film and classic carpal tunnel views. In such cases, "spot" radiographs may be helpful.     

Tuberculous tenosynovitis of the wrist: MRI findings in three patients

 We report recent MRI findings in patients with tuberculous tenosynovitis of the wrist. Marked synovial thickening around the flexor tendons and fluid in the tendon sheath were clearly shown on MRI. Post-contrast study was useful in distinguishing the thick tenosynovium from the surrounding structures and fluid in the tendon sheath. The well-enhanced tenosynovium was also seen in the carpal tunnel in all cases. On the basis of these findings, we could easily distinguish tenosynovitis from other soft-tissue-mass lesions, such as tumors or infected ganglia. Tuberculous tenosynovitis is often not diagnosed early, and its differentiation from soft tissue tumors may be clinically difficult. MRI, particularly post-contrast study, is useful for early diagnosis of, and planning treatment for, tuberculous tenosynovitis.     

High-resolution computed tomography of the wrist in patients with carpal tunnel syndrome

High resolution computed tomography (CT) was used to scan the wrists of 19 patients with idiopathic carpal tunnel syndrome. Thirteen normal volunteers were used as controls. Measurements obtained from the CT images included the cross-sectional area of the carpal tunnel, the relative amount of synovium within the carpal tunnel, the attenuation coefficient of the carpal tunnel, and the thickness of the transverse carpal ligament. No significant difference in any of these measurements was found when comparing the wrists of symptomatic patients with controls. High resolution CT of the wrist does not appear to be of value in the preoperative evaluation of patients with idiopathic carpal tunnel syndrome.     

Hand anomalies in Crouzon syndrome

 Objective. To review the hand radiographs of patients with Crouzon syndrome, to look for extracranial manifestations of the condition at this site. Design. The hand radiographs of those with Crouzon syndrome attending the Craniofacial Service at Great Ormond Street between 1985 and 1996 were reviewed. Results. Thirty-three patients underwent a total of 34 radiographs, one patient having had a serial study. This revealed a range of minor anomalies. Most striking was the presence of carpal fusions in four cases, a feature which has not previously been reported. Conclusion. The hands of Crouzon syndrome may have anomalies including carpal fusions, and these results are evidence that the condition may produce subtle effects on the hands.     

Ultrasound-guided procedures around the wrist and hand: How to do

Ultrasound has emerged as a low-cost, radiation-free and effective imaging technique to detect joint abnormalities and to guide percutaneous procedures. Being superficial, wrist and hand tendons and joints represent a good target to perform such procedures using ultrasound guidance. This kind of approach allows for a clear and real-time visualization of the needles during their whole path. In this setting, the knowledge of technical aspects and tips is essential to act in the most accurate way on target tissues that can be as small as a few millimetres. The aim of this review is to summarize the local treatments of inflammatory and degenerative disease described in literature (such as treatment of De Quervain's tenosynovitis, trigger finger, trapezio-metacarpal joint osteoarthritis, etc.), emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the wrist and hand.     

Role of MR imaging in chronic wrist pain

Magnetic resonance (MR) imaging for chronic wrist pain is challenging. Correct assessment of the triangular fibrocartilage, hyaline cartilage, ligaments, and tendons has become mandatory for comprehensive decision making in wrist surgery. The MR technique, potential and limits of MR imaging in patients with chronic wrist pain will be discussed. MR arthrography with injection of gadolinium-containing contrast material into the distal radioulnar joint is suggested for evaluation of the triangular fibrocartilage. The clinically meaningful ulnar-sided peripheral tears are otherwise hard to diagnose. The diagnostic performance of MR imaging for interosseous ligament tears varies considerably. The sensitivity for scapholunate ligament tears is consistently better than for lunotriquetral ligament tears. Gadolinium-enhanced MR imaging is considered to be the best technique for detecting established avascularity of bone, but the assessment of the MR results remains challenging. Most cases of ulnar impaction syndrome have characteristic focal signal intensity changes in the ulnar aspect of the lunate. Avascular necrosis of the lunate (Kienböck’s disease) is characterized by signal changes starting in the proximal radial aspect of the lunate. MR imaging is extremely sensitive for occult fractures. Questions arise if occult posttraumatic bone lesions seen on MR images only necessarily require the same treatment as fractures evident on plain films or computed tomography (CT) images. MR imaging and ultrasound are equally effective for detecting occult carpal ganglia. Carpe bossu (carpal boss) is a bony protuberance of a carpometacarpal joint II and III which may be associated with pain.     

Synovial sarcoma of the hand

We report on a 23-year-old woman with a poorly differentiated synovial sarcoma on the palm of her hand which presented as a painless nodule. The MRI findings are presented along with the clinical and pathologic features. Becaue of similar morphological features, these tumors can be confused with benign lesions such as aggressive fibromatosis or ganglion cysts, especially when very small. The possibility of a synovial sarcoma mimicking a benign lesion needs to be considered when the mass does not have an unequivocal benign diagnosis on MR imaging. Following wide resection and reconstruction, our patient has been disease free with good function for 28 months.     

Hand and wrist imaging using a low-field dedicated MRI system

Summary Purpose of this study was to evaluate the diagnostic value of a low field dedicated MRI system in hand and wrist imaging. All 308 exams of the hand and wrist, that were performed on a low-field dedicated MRI system (Artoscan, Esaote Biomedica, Italy) in our institution in 1996, and high-field MRI exams performed in addition as part of the diagnostic work-up, were evaluated and correlated to final operative (n = 64) and histologic (n = 12) reports. 90 % of all low-field MRI scans stated a diagnosis according to clinical suspicion. In 62 % the clinical question was answered, and in 26 % additional pathologies were identified. An MR-diagnosis completely different from the clinical suspicion was stated in 2 %. High field exams contributed additional information in 6 of 36 patients. In 3 patients a tumor was not shown completely in the limited field-of-view of the dedicated low-field MRI-system. Frequency-selective fat-suppression pulse sequences and a better spatial resolution were the reasons for the additional information obtained in the other three patients. Low-field dedicated MR-imaging is a valuable method in the extensive work-up of the hand and wrist. Osseous, ligamentous and tendinous pathologies are well depicted. Large or infiltrative tumors should be referred to a high-field system.      

Tendon involvement in rheumatoid arthritis of the wrist: MRI findings

Objective. To evaluate the distribution and extent of wrist tendon alterations in patients with active rheumatoid arthritis (RA) using magnetic resonance imaging (MRI). Design and patients. Forty-three clinically active RA patients with an illness duration of less than 4 years and no clinical evidence of tendons tears were enrolled in the study. There were 10 men and 33 women, with an average age of 52 years (range 33– 63 years). MRI of both wrists, with one exception, was performed at 1.0 T using T1- and T2-weighted sequences (slice thickness 3 mm). Twelve healthy subjects (8 women, 4 men; mean age 31 years) were also evaluated as a control group. Two radiologists reviewed each of four schematic anatomical regions (volar, dorsal, ulnar, radial) for the degree of tendon and tendon sheath alterations using two progressive scales. Results. In the control group all tendons had homogeneous low signal intensity on all sequences. A small amount of fluid was found in six subjects but the diameter was always less than 1 mm. In the patient group minimal fluid (<2 mm) was found in 35 (41%) wrists, grade 2 fluid (<2>5 mm) in 26 (31%) and grade 3 fluid (>5 mm) in 24 (28%). Fifty-nine (69%) of the grade 1 changes were in the volar compartment but grade 2 involvement was evenly distributed. Grade 3 changes were most common in the dorsal compartment and combined grade 2 and 3 in the dorsal and ulnar compartments were 32 (38%) and 25 (30%) compared with 16 (18%) and 17 (20%) respectively in the volar and radial compartments. The tendons were normal (grade 0) in 47 (46%) wrists. A maximum tendon signal change (grade 1) was demonstrated in 28 wrists (32%). When associated with other individual tendons grades this grade was demonstrated in the dorsal compartment in 30 (35%) wrists, in the volar compartment in 12 (14%), in the radial compartment in 17 (20%) and in the ulnar compartment in 26 (30%). A partial tear (grade 2) was detected in 7 (8%) wrists, all involving the dorsal and ulnar compartments; five underwent surgical repair and one proved to have a complete rupture of extensor digitorum. Three (3%) had a grade 3 complete tendon tear: all of these were in extensor tendons. Surgical repair was successful in one case but two ruptured again within 3 months. Conclusions. Low grades of peritendinous effusion were more common in the volar compartment whereas moderate and high degrees of tendon sheath fluid collection and/or pannus and signs of tendonitis were more frequent in the dorsal and ulnar tendon sheaths. Received: 20 January 2000 Revision requested: 24 February 2000 Revision received: 25 October 2000 Accepted: 19 December 2000     

Sonography of the finger flexor and extensor system at the hand and wrist level: findings in volunteers and anatomical correlation in cadavers

We present a review of sonography of the flexor and extensor system of the hand and wrist in volunteers and cadavers. CT tenography also was performed in cadaveric specimens. Anatomical structures of the extensor system that were assessed with sonography included the extensor tendons and insertions, retinaculum, and dorsal hood. On the flexor side, the variable relationship between the flexor superficialis and profundus could be appreciated. Volar plates, tendon insertions, and annular pulleys could also be investigated. Sonography can show details of the finger flexor and extensor system.