Ultrasonography of the Upper Extremity: Hand and Wrist

119 Pages·2014·8.14 MB·English

by  Ferdinando Draghi (auth.)

Ferdinando Draghi
Ultrasonography of
the Upper Extremity
Hand and Wrist
123
Ultrasonography of the Upper Extremity
Ferdinando Draghi
Ultrasonography of the
Upper Extremity
Hand and Wrist
123
FerdinandoDraghi
Unitof Ecography
Instituteof Radiology
FoundationIRCCS
PoliclinicoSan Matteo
Pavia
Italy
RevisedandenlargedEnglisheditionof‘‘Ecografia:PolsoeMano’’byFerdinandoDraghi.
AthenaSrl,2011,Italy.TranslatedfromtheItalian,withtheauthor,byMarianEverett
Kent
ISBN 978-3-319-02161-4 ISBN 978-3-319-02162-1 (eBook)
DOI 10.1007/978-3-319-02162-1
SpringerChamHeidelbergNewYorkDordrechtLondon
LibraryofCongressControlNumber:2013954793
(cid:2)SpringerInternationalPublishingSwitzerland2014
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Foreword
The field of musculoskeletal sonography has undergone unprecedented
development over the past decade, thanks to ongoing technological
refinements, the inherent advantages of ultrasound imaging itself (low
cost, widespread availability, capacity for dynamic studies, excellent
acceptance by patients), its value in imaging-guided therapeutic inter-
ventions, and—last but by no means least—the enthusiasm of the
sonographers who have pioneered the field of musculoskeletal ultraso-
nography and devoted years in promoting its diffusion.
The shortcomings of ultrasound are well-known: its operator
dependency and the time and effort required to learn the art. Most
sonographershavevividlypainfulmemoriesoftheirfirstencounterwith
the musculoskeletal system: its anatomical complexities, the technical
difficultiesinvolvedinitssonographicexploration,problemsinvolvedin
interpreting the findings! This is why courses and workshops on the
theory and above all the practical aspects of musculoskeletal ultra-
sound—like those organized by the French-speaking Groupe d’Echog-
raphiste Appareil Locomoteur and the Socie´te´ d’imagerie Musculo-
Squelettique or the Societa` Italiana Ultrasonologia in Medicina e Bio-
logia (SIUMB)—have met with such success.
Ferdinando Draghi of the University of Pavia—the author of
Ultrasonography of the Upper Extremity—is a key figure in the SI-
UMB’s Study Group on Musculoskeletal Sonography. His contribu-
tions in this field range from invited lectures during national and
internationalcongresses,alonglistofjournalarticlesandmonographs,
and active leadership of the SIUMB’s official organ, The Journal of
Ultrasound(publishedbySpringer),whichhasgrownremarkablyinthe
years that Draghi has been its Editor in Chief.
With this monograph—his latest publication—Draghi explores one
oftheanatomicregionsthathavebenefitedmostfromthetechnological
revolutionsthathavebeengoingoninthefieldofultrasonography.The
chapters in this book provide clear, concise, and complete coverage of
the anatomy of the hand and wrist—tendons, nerves, vascular struc-
tures—and main pathologic conditions encountered in this area. The
textisenrichedwithhelpfuldiagrams,magneticresonanceimages,anda
wealth of high-quality ultrasound images acquired with state-of-the art
scannersandcarefullylabeledtofacilitaterecognitionofeachandevery
v
vi Foreword
structure. Key points are summarized in practical tables. Readers will
find useful details on anatomy, examination techniques, and the
appearance of the various structures under normal and pathological
conditions. And, reading between the lines, they will undoubtedly
appreciate—and hopefully come to share—Dr. Draghi’s undying fasci-
nation with this sector of medical imaging. Enjoy!
Paris, France Dr. Stefano Bianchi
President de la SIMS
Socie´te´ d’Imagerie Musculo-Squelettique
Paris, France
Contents
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Extensor Tendons of the Wrist: Anatomy . . . . . . . . . . . . . 11
3 Extensor Tendons of the Wrist: Pathologic Conditions. . . . 21
4 De Quervain’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5 Intersection Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6 Wartenberg’s Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . 35
7 Flexor Carpi Radialis, Palmaris Longus, and Flexor
Carpi Ulnaris Tendons: Anatomy and Pathology. . . . . . . . 39
8 Carpal Tunnel: Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . 43
9 Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 49
10 Guyon’s Canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
11 Tendons of the Digits: Anatomy and Pathology. . . . . . . . . 61
12 Pulleys and the Sagittal Bands . . . . . . . . . . . . . . . . . . . . . 67
13 Dupuytren’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
14 Ulnar Collateral Ligament of the Metacarpophalangeal
Joint of the Thumb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
15 Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
16 Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
17 Ganglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
vii
viii Contents
18 Foreign Bodies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
19 Vascular Disorders of the Hands and Wrists. . . . . . . . . . . 101
20 Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
20.1 Occult Fracture of the Third Finger . . . . . . . . . . . . . 107
20.2 Intersection Syndrome with Fluid in the Sheaths
of the Second and Third Compartments. . . . . . . . . . . 107
20.3 Allergic Tenosynovitis of the Extensor Tendons. . . . . 107
20.4 De Quervain’s Disease in a 9-Year-Old Girl . . . . . . . 109
20.5 Intersection Syndrome in a Patient with
Tenosynovitis Involving Only the Extensor
Carpi Radialis Brevis . . . . . . . . . . . . . . . . . . . . . . . 109
20.6 Wartenberg’s Syndrome After Cephalic
Vein Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . 110
20.7 Flexor Carpi Radialis Tenosynovitis in a Patient
with Reversed Palmaris Longus . . . . . . . . . . . . . . . . 110
20.8 Carpal Tunnel Syndrome in a Patient with a Bifid
Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
20.9 Post-traumatic Palmar Cutaneous Nerve
Encasement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
20.10 Traumatic Rupture of the Flexor Carpi
Ulnaris Tendon. . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
20.11 Ultrasound Examination After Reconstruction
of the Extensor Tendon of the Third Finger. . . . . . . . 112
20.12 Soft Tissue Sarcomas with Displacement of the
Extensor Tendon of the Third Finger . . . . . . . . . . . . 112
20.13 Trigger Finger in a Patient with Dupuytren’s
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
20.14 Fracture of the First Metacarpal Mimicking a Tear
of the Ulnar Collateral Ligament of the
Metacarpophalangeal Joint of the Thumb. . . . . . . . . . 113
20.15 Extensor Carpi Ulnaris Tendon Instability
in a Patient with Rheumatoid Arthritis . . . . . . . . . . . 114
20.16 Extensor Tendon Tenosynovitis in a Patient
with Radiocarpal Osteoarthritis. . . . . . . . . . . . . . . . . 114
20.17 Moderately Painful, Pulsating Lesion on the Volar
Side of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . 116
20.18 Complete Rupture and Subsequent Surgical
Reconstruction of the Deep Flexor Tendon
of the Fifth Finger . . . . . . . . . . . . . . . . . . . . . . . . . 116
20.19 Digital Varicosities in a Patient
with Raynaud’s Phenomenon. . . . . . . . . . . . . . . . . . 116
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
1
Introduction
Content Overview Veins
Tendons of the digits
Joints
Flexor digitorum superficialis
Distal radioulnar joint
Flexor digitorum profundus
Radiocarpal joint
Extensors
Mediocarpal joint
Sagittal bands
Tendons on the dorsal aspect of the wrist
Pulleys
Abductor pollicis longus and extensor
pollicis brevis Collateral ligaments
Extensor carpi radialis longus and brevis
Of the metacarpophalangeal joints
Extensor pollicis longus
Of the digits
Extensor digitorum communis
Palmar fascia
and extensor indicis proprius
Extensor digiti minimi proprius
Extensor carpi ulnaris
Tendons on the volar aspect of the wrist The wrist is composed of three joints: the distal
radioulnar joint (Fig. 1.1a), the radiocarpal joint
Flexor carpi radialis, palmaris longus,
(Fig. 1.1b),andthemediocarpaljoint(Fig. 1.1c).
flexor carpi ulnaris
Under physiologic conditions, there is no com-
Flexor digitorum superficialis
municationbetweenthethreejointcavities[1,2].
Flexor digitorum profundus, flexor
The actions of the radiocarpal and mediocarpal
xpollicis longus
joints are complementary, the former being
Nerves responsiblemainlyforextensionandulnardevi-
ation (adduction) of the wrist, the latter for its
Ulnar nerve
flexionandradialdeviation(abduction).
Radial nerve
The radioulnar joint is also involved in pro-
Median nerve
nosupination of the wrist.
Arteries Ofthevariousstructurescomposingthewrist
(bones, synovial membranes, joint capsules,
Ulnar artery
etc.), the tendons are the ones most frequently
Radial artery
examined with ultrasonography. They can be
Median artery
divided into two main groups: dorsal and volar.
F.Draghi,UltrasonographyoftheUpperExtremity, 1
DOI:10.1007/978-3-319-02162-1_1,(cid:2)SpringerInternationalPublishingSwitzerland2014
2 1 Introduction
Fig.1.1 Thejointsofthewrist:thedistalradioulnar(a)theradiocarpal(b)andthemediocarpal(c)joints.Thereis
normallynocommunicationbetweenthethreejoints
Table1.1 Osseofibrous tunnels (or compartments) on carpi ulnaris (Fig. 1.3a); the second layer con-
thedorsalaspectofthewrist
sists of the flexor digitorum superficialis
Compartment1 Abductorpollicislongusand (Fig. 1.3b); the third includes the flexor digito-
extensorpollicisbrevistendons
rum profundus and flexor pollicis longus
Compartment2 Extensorcarpiradialislongusand
(Fig. 1.3c), and the fourth is composed of the
extensorcarpiradialisbrevis
pronator quadratus (Fig. 1.3d).
tendons
The tendons of the flexor digitorum superfi-
Compartment3 Extensorpollicislongustendon
cialis and profundus muscles (four tendons
Compartment4 Extensordigitorumcommunisand
each), the flexor pollicis longus tendon (which
extensorindicispropriustendons
has its own synovial sheath), and the median
Compartment5 Extensordigitiminimiproprius
nerveallliewithinthecarpaltunnel(Table 1.3),
tendon
which is formed by the carpal bones and the
Compartment6 Extensorcarpiulnaristendons
flexorretinaculum(alsoknownasthetransverse
carpalligament)[2,3](Fig. 1.4);theflexorcarpi
radialis,flexorcarpiulnaris,andpalmarislongus
The tendons on the dorsal aspect of the wrist tendons lie outside this tunnel.
(Table 1.1) run through 6 osseofibrous tunnels Superficial to the carpal tunnel lies the Gu-
[3–5] (Fig. 1.2) or compartments. The floor of yon’s canal, a space formed by the flexor reti-
these tunnels is formed by the radius, the ulna, naculum (floor) and the palmar carpal ligament
and the distal radioulnar joint; the roof consists (roof). The ulnar artery and ulnar nerve both
of the extensor retinaculum (also known as the pass through this canal (Fig. 1.4a).
dorsal carpal ligament). Inadditiontotheulnarnerve(Figs. 1.4a,1.5a
Each compartment-regardless of the number andb),thewristalsocontainstheradial(Fig. 1.5c
of tendons it contains is lined with a single andd)andmediannerves(Fig. 1.5e–h).
synovial sheath. On the volar side of the wrist, All three of these nerves and many of their
therearefourmusclelayerswiththeirrespective branches(includingthosethatareextremelyfine)
tendons [3, 4] (Table 1.2) (Fig. 1.3). The most can be assessed sonographically. As noted, the
superficial layer includes the flexor carpi radia- ulnar nerve runs through the Guyon’s canal
lis, the flexor palmaris longus, and the flexor (Fig. 1.5a),andatthislevel,ithasusuallyalready