Dynamic High Resolution Sonography (d-hrus) of the hand: a detailed didactic approach.

Transcription

1 Dynamic High Resolution Sonography (d-hrus) of the hand: a detailed didactic approach. Poster No.: C-1634 Congress: ECR 2012 Type: Educational Exhibit Authors: E. Fabbro, A. Corazza, A. Arcidiacono, F. Nosenzo, C Martini, E. Silvestri ; Genoa/IT, Genova/IT Keywords: Musculoskeletal system, Ultrasound, Education, Motility DOI: /ecr2012/C-1634 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Learning objectives The purpose of our educational exhibit is to: Illustrate the normal anatomy and normal d-hrus appearance of hand structures. Describe a systematic technique for d-hrus evaluation of such structures. Produce anatomical schemes with didactic purpose and show correlations with sonographic imaging. Background The hand can be studied both from the ventral side and from the dorsal side, and each of those contains a group of small structures that are extremely important for hand functionality. Currently, HRUS represents the first level imaging in the hand evaluation. For each of the following structures we will provide a dedicated HRUS image compared with a detailed anatomic scheme, and a practical guide on "how we do" a d-hrus scan: VENTRAL SIDE: Palmar aponeurosis Flexor digitorum tendons Metacarpophalangeal and interphalangeal joints DORSAL SIDE: Extensor digitorum tendons Ulnar collateral ligament of the thumb Imaging findings OR Procedure details The exam can be commenced either from the dorsal or the palmar side of the hand. VENTRAL SIDE Page 2 of 24

3 Check-list: Palmar aponeurosis Flexor digitorum tendons Metacarpophalangeal and interphalangeal joints The hand lies on the table with the ventral side facing up (Fig. 1) Page 3 of 24

4 Fig. 1: 1. Hand position to evaluate the palmar side of the hand 1) Palmar aponeurosis Page 4 of 24

5 The bundles of palmar aponeurosis can be assessed using axial scans, as they run over the flexor tendons. Palmar fibromatosis (Dupuytren's disease) can be seen as small subcutaneous hypoechoic nodules or focal thickening. The involvement of flexor digitorum tendons can be tested using dynamic scans. 2) Flexor digitorum tendons Flexor tendons can be evaluated with short axis scans on the carpal tunnel, moving the probe towards the fingertips (Fig. 2). Page 5 of 24

6 Fig. 2: 2. Probe position to evaluate the flexor digitorum tendons on the short axis Page 6 of 24

7 During this scan, the tendon course is not perfectly straight, thus slight probe tilting may be necessary to avoid anisotropy artifacts. Going distally, the changing relationship between superficial and deep flexor tendons can be seen (Figs. 3, 4 and 5). Fig. 3: 3. Anatomical scheme of flexor digitorum tendons. *, flexor digitorum profundus tendon; circles, flexor digitorum superficialis tendons; M, metacarpal bone; P1, P2, P3, proximal, middle and distal phalanges Page 7 of 24

8 Fig. 4: 4. US axial scan of the hand palm. FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; M, metacarpal bone; L, lumbrical muscle; white arrowheads, common digital nerve; void arrowheads, common digital arteries (Doppler signal in red); *, interosseous muscles Page 8 of 24

9 Fig. 5: 5. M, metacarpal bones; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundis tendon; L, lumbrical muscles; IO, interosseous muscles; N, common digital nerve; A, common digital artery Longitudinal scans are useful for passive dynamic evaluation (Fig. 6 and 7). Reflection pulleys can be seen on both axial and longitudinal scans. Page 9 of 24

10 Fig. 6: 6. Probe position to evaluate the flexor digitorum tendons on the long axis Page 10 of 24

11 Fig. 7: 7. US longitudinal scan of the third flexor digitorum tendon. FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; M, metacarpal bone 3) Metacarpophalangeal and interphalangeal joints The metacarpophalangeal and interphalangeal joints must be assessed using longitudinal scans (Figs. 8 to 12). Collateral ligaments can be seen by placing the probe on a longitudinal plane on both the radial and ulnar side of the joints. Page 11 of 24

12 Fig. 8: 8. Probe position to evaluate the metacarpophalangeal joints on the long axis Page 12 of 24

13 Fig. 9: 9. Longitudinal scan of the metacarpophalangeal joint, palmar side. M, metacarpal head; P1, proximal phalanx; T, flexor tendon; *, palmar plate; circle, proximal synovial recess; arrowheads, A1 pulley Page 13 of 24

14 Fig. 10: 10. Probe position to evaluate the interphalangeal joint on the long axis Page 14 of 24

15 Fig. 11: 11. Proximal interphalangeal joint longitudinal scan, palmar side. P1, proximal phalanx; P2, middle phalanx; T, flexor tendon; *, palmar plate Fig. 12: 12. Distal interphalangeal joint longitudinal scan, palmar side. P2, middle phalanx; P3, distal phalanx; T, flexor digitorum profundus tendon DORSAL SIDE Check-list: Extensor digitorum tendons Ulnar collateral ligament of the thumb Dorsal compartment can be assessed with the hand lying on the table, with the palm facing down (Fig. 13). Page 15 of 24

16 Fig. 13: 13. Probe position to evaluate the dorsal compartment of the hand. Page 16 of 24

17 Fig. 14: 14. Anatomical scheme of the dorsal compartment of the hand. Void arrowheads, extensor digitorum communis tendon; white arrowheads, extensor digitorum superficialis tendon; *, extensor digitorum profundus tendon; M, metacarpal bone; P1, proximal phalanx; P2, middle phalanx 1) Extensor digitorum tendons Extensor digitorum tendons can be assessed using axial scans, moving the transducer from the carpus distally to the fingertips. Tendons become very thin distally, then transform into lamina extensoria (Figs. 14 to 20). Page 17 of 24

18 Fig. 15: 15. Probe position to evaluate the metacarpophalangeal joint and extensor digitorum tendon Page 18 of 24

19 Fig. 16: 16. Metacarpophalangeal joint longitudinal scan, dorsal side. M, metacarpal head; P1, proximal phalanx; arrowheads, extensor tendon Fig. 17: 17. Longitudinal scan, dorsal side. Arrowheads indicate the course of the extensor tendon. P2, middle phalanx Page 19 of 24

20 Fig. 18: 18. Probe position to evaluate the proximal and distal interphalangeal joints Page 20 of 24

21 Fig. 19: 19. Proximal interphalangeal joint longitudinal scan, dorsal side. P1, proximal phalanx; P2, middle phalanx; arrowheads, extensor tendon Fig. 20: 20. Distal interphalangeal joint longitudinal scan, dorsal side. P2, middle phalanx; P3, distal phalanx; arrowheads, estensor digitorum profundus tendon 2) Ulnar collateral ligament of the thumb The most common ligament injury affects the ulnar collateral ligament of the thumb. Note that small avulsion fragments can easily be detected using US (Figs. 21 and 22). Page 21 of 24

22 Fig. 21: 21. Probe position to evaluate the ulnar collateral ligament of the thumb Page 22 of 24

23 Fig. 22: 21. Ulnar collateral ligament of the thumb. M, metacarpal head; P1, proximal phalanx; arrowheads, ulnar collateral ligament of the thumb Conclusion d-hrus allows a quick, real-time evaluation of such structures and, in particular, a detailed visualization of their anatomy. In addition, dynamic evaluation adds several important informations about the biomechanics of hand structures. Personal Information References [1] Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, Kainberger F, Klauser A, Martinoli C, McNally E, O'Connor PJ, Peetrons P, Reijnierse M, Remplik P, Silvestri E. Musculoskeletal Ultrasound Technical Guidelines. European Society of Musculoskeletal Radiology. [2] Martino F, Silvestri E, Grassi W. Musculoskeletal sonography: technique, anatomy, semeiotics and pathological findings in rheumatic diseases. Springer, [3] Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Springer 2007: Page 23 of 24

24 [4] Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Saunders, [5] Van Holsbeeck M, Introcaso J. Musculoskeletal Ultrasound 2nd ed. Mosby, [6] McNally E. Practical Musculoskeletal Ultrasound. Elsevier, [7] Chhem R, Cardinal E. Guidelines and Gamuts in Musculoskeletal Ultrasound. WileyIEEE, [8] Bradley M, O'Donnell P. Anatomy.CambridgeUniversityPress, Atlas of Musculoskeletal ltrasound [9] Marcelis S, Daenen B,FerraraMA. Peripheral Musculoskeletal Ultrasound Atlas. Thieme, [10] Balboni G, et al., Anatomia Umana III ed (2004): [11] Standring S. Anatomia del Gray. Le basi anatomiche per la pratica clinica. Elsevier, 2009: [12] Silvestri E., Muda A., Sconfienza L.M. Normal Ultrasound Anatomy of the Musculoskeletal System, 2011:45-62 Springer, 2011 Page 24 of 24