수부와팔꿈치의초음파소견

원광대학교병원

류마티스내과

이창훈

Contents

Finger

Flexor surfaces

Extensor surfaces

RA vs OA 감별포인트

Wrist

Flexor , Extensor anatomy

Trigger finger

Carpal tunnel syndrome

Guyon canal

De Quervain’s Disease

Intersection syndrome

Finger Anatomy ; Flexor surface

Flexor digitorum superficialis tendon slips can

be seen peeling off the Profundus portion

Flexor digitorum profundus(Arrow) insertion

onto the distal phalanx

Finger Anatomy ; Flexor surface

Anatomy of A1 pulley

• Overlying MCPJ

• Thin hyporeflective band

• Movement independently

of finger

Finger Anatomy ; Flexor surface

Trigger Finger

Normal

Trigger Finger

Trigger finger injection

Finger Anatomy; Flexor surface

Tenosynovitis Dark halo around the tendon

Hypoechoic or anechoic thickened tissue with or without fluid

within the tendon sheath

Fluid surrounds the tendon

slight thickening of synovial lining of tendon sheaththickened low-reflective halo

Finger Anatomy; Extensor surface

Dorsal(Extensor) hood ; pulley 와같은역할

Central slip ; Ext. tendon 의연장선

Rupture ; boutonniere-deformity

Finger Anatomy; Extensor surface

Dorsal Hood Injury Abnormal tendon movement in dorsal hood lesions

Extensor tendon has displaced around the margin of the

metacarpal head

Tendon subluxation

Finger Anatomy; Extensor surface

Central slip

Extensor tendon to its insertion

boutonniere-deformityElson Test

OA osteophyte of Hand

Step-up bony prominence at the bony margin that is

visible in two perpendicular planes

PIP joints

Rheumatoid arthritis

RA

Synovial hypertrophy ; primary event visible

• 움직이지않고눌려지지않는 hypoechoic lesion in joint

(sometimes may be isoechoic or hyperechoic)

• Doppler (+) ; microvessel within synovium, sign of active

disease synovitis

Practical Musculoskeletal Ultrasound

Rheumatoid arthritis

RA

Erosion

• 두개의수직평면에서관찰되는골표면연결선의끊김(discotinuity)

• 특이적이지는않다

• 2nd MCP ; > 2mm 이상일경우의미(+)

Synovial hypertrophy

no synovial thickening

without bulging over the line linking tops of

thebones

bulging over the line linking tops of the

periarticular bones

bulging over the line linking tops of the

periarticular bones with extension RMD Open 2017;3:e000428

Gr2 Gr3

Grading of synovitis on Grey scale and Doppler

no flowing the synovium

single vessel signals

confluent vessel signals in less than

half of the area of synovium

vessel signals in more than

half of area of the synoviumRMD Open 2017;3:e000428

Combined Eular-Omeract PDUS score

RMD Open 2017;3:e000428

minimal

moderate

severe

Rheumatoid arthritis

RA

Undifferentiated arthritis에서 early RA 소견• OA와감별 ; Thickness of synovial hypertrophy

• Power doppler양성; RA 로발전가능성– 1개관절 ; OR 9.9

– 2개관절 ; OR 17.4

– 3개이상 ; OR 48.7Clinical and Experimental Rheumatol 2010;28:686

• Erosion ; 특이적이지는않다

Diagnostic value of erosive RA differentiated from hand OA

Joint Bone Spine 2019

G 0 No erosion

G 1 Erosion < 2mm

G 2Erosion 2-3 mm

or two erosion < 2mm

G 3Erosion > 3mm

or multiple erosionat least two joint facets eroded or

at least one joint facet eroded at grade 2 on US

good sensitivity (68-72.1%) and specificities excellent (89.1-100%)

Finger Anatomy; Base of Thumb

Base of Thumb

ulnar collateral ligament

Position to locate and stress the adductor

aponeurosis and UCL

Finger Anatomy; Base of Thumb

Ulnar collateral ligament rupture

Skier’s thumb

gentle flexion of the IPJ

• Hyporeflective mass

• proximal metacarpal head

• displaced UCLt

Wrist Joint; Extensor

Extensor Wrist (6 compartments)

Lister’s tubercle

Wrist Joint; Extensor

Axial anatomy extensor wrist

Listers tubercle(*) separates EC2 and EC3 first compartment on distal radius,

close to EC2

Wrist ; EC1 and EPL (EC3) crossing EC2

Rotation of probe to remain axial

to EPL tendon at CMC level

Intersection or crossover syndrome occurs

where EC1 crosses EC2 in the distal

forearm.

Carpal Tunnel Syndrome (CTS)

Nerve entrapment due to Thickening of flexor retinaculum

Flattened as it passes beneath flexor retinaculum

Triad of Ultrasound finding (CTS)

Palmar bowing of the flexor retinaculum (>2 mm

beyond a line connecting the pisiform and schaphoid)

Wrist-to-forearm ratio of Median Nerve >1.4

Increased cross sectional area >10 mm2 at proximal

carpal tunnel (scaphoid–pisiform level)

Triad of CTS

palmar bowing>2mm Wrist-to-Forearm ratio>1.4

cross sectional area >10 mm2

flexor retinaculum

US Assessment of CTS

comparing at the level of the carpal tunnel (CSAc) with proximally

(CSAp) at the level of the pronator quadratus muscle

Radiology: Volume 250: Number 1—January 2009

Carpal Tunnel Syndrome

change in calibre of the median nerve

under the flexor retinaculum

‘notch sign’

Carpal Tunnel Syndrome injection

Carpal Tunnel Syndrome injection

In-plane ulnar approach

Out-plane

Medicine journal,Volume 93, Number 29.

Carpal Tunnel Syndrome injection

J Ultrasound Med 2008; 27:1485–1490

Wrist ; Flexor; ulnar side

Carpal tunnel and Guyon’s canal

Flexor Carpi Ulnaris (FCU)

carpal tunnel carpal tunnel and Guyon’s canal

Wrist: Radial

De Quervain’s Disease radial side pain

Thickening of retinaculum of extensor compartment 1

best seen at radial styloid

anechoic compressible fluid

Wrist: Radial; De Quervain’s Disease

Anechoic compressible fluid (arrow) and echogenic peripheral

synovial hypertrophy (arrowheads)

finkelstein test

Wrist: Radial; De Quervain’s Disease

Ultrasound guided injections of the 1st extensor compartment

De Quervain’s vs Intersection syndrome

De Quervain’s

Distal Intersection

Proximal Intersection

Wrist: Radial

Proximal intersection syndrome

‘Oarsman’s forearm’ , ‘crossover syndrome’

Friction between extensor carpi radialis brevis and longus

tendons (EC2) with myotendinous junctions of abductor pollicis

longus and extensor pollicis brevis (EC1)

Wrist: Radial; Proximal intersection syndrome

Fluid in the tendon sheaths (arrows) at the crossover of

abductor pollicis longus and extensor carpi radialis

tendons (EC1 & EC2)

Wrist: Radial ; Distal Intersection syndrome

Crossover between the extensor carpi radialis brevis and

longus tendons (second compartment) and the extensor

pollicis longus tendon (third compartment)

Just distal to Lister’s tubercle

extensor carpi radialis tendons

Extensor pollicis longus

De Quervain’s vs Intersection syndrome

De Quervain’s

Distal Intersection

Proximal Intersection

Take Home Message

RA

Synovial proliferation + hyperemia; synovitis

Trigger finger ; A1 pulley

Skier’s thumb ; UCL

CTS ;

Palmar bowing ; >2 mm at the pisiform and schaphoid

Wrist-to-forearm ratio >1.4

cross sectional area >10 mm2

De Quervain’s vs Intersection syndrome

APL, EPB : EC1, EC3 crossover EC2