common wrist/hand pathologymedian nerve cross-sectional area measurement csa of the median nerve...
TRANSCRIPT
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Musculoskeletal US:Common Wrist Pathology
Kenneth S. Lee, MDAssociate Professor of Radiology
University of Wisconsin School of MedicineDivision of Musculoskeletal Radiology
@kenlee8799
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Disclosures
Grants: NBA/GE, Mitek Research: Supersonic Imagine Royalties: Elsevier
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Objectives
Show that ultrasound is well-suited to evaluate the normal structures of the wrist
Discuss the normal US appearance and dynamic movement of the ECU
Demonstrate common pathology involving the wrist
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Bone Anatomy
Scaphoid
LunateTriquetrum
PisiformTrapezium
Trapezoid CapitateHamate
PA View
8 Carpal Bones 2 Carpal Rows Radiocarpal Jt DRUJ
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Pisiform
Hook of the HamateTrapezium Ridge
Carpal Tunnel View
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Intrinsic Ligaments
SLLTFC
LTL
MRI T2-W MRI PD-W
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Three Compartments
1. Radiocarpal Joint2. DRUJ3. Midcarpal Joint
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Musculoskeletal Ultrasound
Indications Focused but complete exam Characterize soft tissue mass
Cyst or Solid US-Guided Procedures
Injection Aspiration
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Flexor Tendons
FCU
FPL
FCR
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Volar Wrist: Technique
Median Nerve Flexor Tendons
FCR & Radial Artery Occult Ganglia
Volar Joint Recesses
S
PisFCR
PisS
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Volar Wrist PQRadius
Radius Scaphoid
FCR
R L Cap
R
Pis
D
Radial Ulnar
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Volar Wrist: Flexor Carpi Ulnaris
Pisiform
No synovial sheath
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Normal Peripheral Nerve
US Appearance Hypoechoic Fascicles Hyperechoic Conn Tis
Transverse Honeycomb
Minimal Anisotropy
Silvestri et al. Radiology 1995; 197:291
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Volar Wrist: Median Nerve
Take home point: Tendons more susceptible to anisotropy!!
FCR FCR
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Volar Wrist: CTS
Proximal Enlargement of Median Nerve > 10mm2 cross-sectional area1
> 9mm2 circumferential2
Measure at level of pisiform Distal Nerve Compressed Bowing of the Flexor Retinaculum
1 Chen et al. AJR 1997; 168:5332 Duncan et al 199; 173:681
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Median Nerve - Carpal Tunnel
Radial Ulnar
Scaphoid Pisiform
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Median Nerve - Proximal
Radius Ulna
PQ
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Median NerveCross-Sectional Area Measurement CSA of the median nerve
Carpal Tunnel (C) Pronator Quadratus (P)
Mean CSAc in normals = 9.0 mm2
Difference of CSA to normalize
Δ CSA = CSAc – CSAp
Threshold of 2 mm2
Sensitivity = 99%Specificity = 100%
Klauser A. Radiology 2009;250:171
PQ
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Ulnar Nerve – Guyon Canal
Pisiforma
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Radial Nerve – Superficial Branch
Linda D. Radiographics 2010;30:1373
R
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Volar Wrist: Joint Recesses
Anechoic: Simple fluid If not anechoic
Compressible Noncompressible Hyperemia
Cannot differentiate sterile from septic joint fluid
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Dorsal Wrist: Extensor Tendons
I
II
III IV V
VI
RadiusUlna
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Wrist Ganglia
Most common wrist mass Not compressible!! Dorsal
70% Originates from Scapholunate ligament
Volar Identify between radial artery and FCR Proximal to the radiocarpal joint capsule
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De Quervain’s Tenosynovitis
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Dorsal Wrist: Extensor Tendons
LT EPLECRB ECRB
ECRL
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Extensor Tendons: Tenosynovitis
Can be hyperechoic!
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Dorsal Wrist: EPL Tear
EPL Absent
ECRBECRL
Use Dynamic Imaging!!
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6th Extensor Compartment
Extensor Carpi Ulnaris Tendon (ECU) Own fibro-osseous tunnel Stabilizer of the DRUJ: own subsheath Overlying extensor retinaculum Instability of the ECU: a difficult clinical diagnosis
Spinner and Kaplan, 1970
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6th Extensor Compartment
Pratt et al, 2004
C
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US - MRI Correlation
Pronation
Neutral
Supination
U
U
U
Lee KS. AJR 2009;193:651
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Normal Movement of the ECU
Supinated - Radial Supinated - Ulnar
Supinated - Ulnar
UlnaD
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Summary
Ultrasound is well-suited for evaluating common wrist pathology Tendons – Extensors and Flexors
Dynamic – ECU
Nerves – Median, Ulnar, Radial
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Thank You