대 한 방 사 선 의 학 회 지 1992 ; 28 (2) : 27 5~28 0

Journal of Korean Radiological Society , March , 1992

Sonographic Characterization of Tenosynovitis

Gwy Suk Seo, M.D. , Hyo Keun Lim, M.D. , In Jae Lee, M.D , Kil Woo Lee, M.D. , Sang Hoon Bae, M.D. , Kyung Hwan Lee, M.D.

D epartment of DiagnOstic RadioJogy, CoJJege o[ Medicine. HaJJym University

- Abstract-

Tenosynovitis of the extremities is not uncommon but its diagnosis is not easy owing to its non-specific clinical

manifestation. Thus it was beyond the field of imaging diagnosis so fa r. Recently the development of high resolu­

tion ultrasonogram has aided preoperative imaging diagnosis of tenosynovitis. The authors performed a retrospec­

tive review of 27 patients who had ultrasonography due to tendon pathology(including 18 tenosynovites) by obseπing

sonographic findings and evaluating the diagnostic value of each finding. The overall diagnostic accuracy was 81.1 %

and common sonographic findings were focal swelling of the tendon. well-defined margin of the lesion. preserved

fibrillar pattern. echo change of the lesion site and f1uid collection . Above al l. f1uid collection was the only

statistically significant criterion for diagnosis of tenosynovitis(p<0.05). But its sensitivity was as low as 50%. ln con­

clusion the ultrasonography is useful in diagnosis of tenosynovitis and f1uid collection is of diagnostic value . but

the differentiation between nodular tenosynovitis without f1uid collection and other benign tumor is still beyond

the scope of ultrasonographic diagnosis ‘

Index Words: Ultrasound ‘ Tenosynovitis ‘ Tendinitis

INTRODUCTION

Two main categories of non-traumatic lesion of the

extremities are infla mmatory diseases and tumorous

conditions. which are characterized by quite different

c1inical manifestations and which require different

approach to the management. And usually they come

to need medical a dvice complaining of pain or swell­

ing which is so commonly an early manifestation , but

non-specific . At initial period or sometimes through

the whole disease process , differentia tion between the

two is quite nuisant to the clinicians. As for inflam­

matory diseases , it is especially difficult to diagnose

a nd to differentiate from others. To the c1 inic ians'

luckiness , inflammatory condition of the tendon a nd

peritendinous structures sometimes fall within th e

scope of ultrasonographic examination owing to their

superficial location( 1-5) . In such a context. the

authors observed common findings and tried

ultrasonographic characterization of tendinous in­

flammation and discussed the role and limitation of

ultrasonograthy in diagnosing tendinous in f1am­

m ation .

METHOD

From July 1989 to Sept 199 1. twenty-seven pa­

tients , who had ultrasonography and were diagnos­

ed as tendon or peritendinous pathology , were

selected for a retrospective review. There wer e 17

males a nd 10 fem a les and their m ean age was

34.8(range:6-67 Yrs) . Among them 18 had

tenosynovites , four h ad cystic tumors(two epidermal

inc lusion cysts. one ganglion. one synovial cyst)‘

이 논문은 1991년 11월 29일 접수하여 1992년 1월 9일에 채택되었음

Received November 29, 1991, Accepted Janua ry 9, 1992

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Journal of Korean Radi이 ogical Society 1992 ; 28 (2) : 275~28D

three had tendon rupture and one had a s이id tumor.

Of all , twelve cases(six tenosynovites and six others)

were confirmed by operation and the others were

diagnosed on a clinical basis including labüratory fin­

dings and aspiration cytology. The sonographic

equipment we used were SSD-630(Aloka , Tokyo ,

Japan) and UM-4(ATL , Bothell , USA) with a 5.0 or

7 .5 MHz linear probe designed for small body part in­

vestigations.

We observed ultrasonographic findings with em­

phasis on the change of tendon size , outer margin of

the lesion , fibrillar pattern ofthe tendon at lesion site ,

echo texture of the lesion , and presence of calcificai­

tion or focal fluid collection. And then we evaluated

the significance of individual sonographic feature in

a statistical method using the Chi-square test with

Yates correction

RESULT

The commonest location of tenosynovitis was the

flexor or extensor tendon of the hand and wrist follow­

ed by the Achilles tendon , peroneus tendon , and the

quadriceps tendon in decreasing order of frequen­

cy(Table 1).

The clinical manifestations are listed in Table 2.

Focal swelling and pain are the major complaints and

Fig. 1. A transverse sonogram of the thumb shows swollen tendon and anechoic f1uid collection surrounding the tendon(arrow).

Fig. 2. The fibrillar pattern of the Achilles tendon is preserved(arrow) even in the inflammed area(arrow).

as many as seven patients were presented with overt mass. History of trauma was noted in four patients.

The ultrasonographic findings were as follows :

Table 1. Location of the Lesion in Tenosynovitis Group focal swelling of the tendon (Fig. 1) was found in 15

Location

Finger , Hand Achilles Peroneus Quadriceps Popliteal fossa

Number (%)

11 (6 1.1)

3 (1 6.7) 2 (1.1)

1 (5.6) 1 (5.6)

cases , the margin of the tendon was well defined in

11 cases , but ill-defined in seven cases. the fibrillar

pattern of the tendon was preserved(Fig. 2) in 13

cases, partially disrupted in four cases and complete­

ly lost in one case(In this case, sonographic diagnosis

was erroneous) . Ten lesions showed different echo

texture from the remaining portion of the tendon ,

Table 2. Clinical Manifestations in Tenosynovitis Group six of them were hypoechoic and four were mixed

Manifestation

Focal swelling Pain Mass Limitation of motion Trauma association

Number (%)

9 (50 .0) 7 (38 .9) 7 (38.9) 1 (5 .6) 4 (5.6)

echogenic. Of nine cases with fluid collection(Fig. 3) ,

regional focal fluid collection in three cases and dif­

fuse collection paralleling the tendon course in six

was found. Totally three cases had calcification(Fig.

4 ), one of which proved to be tuberculosis and the

others were diagnosed as non-tuberculous tenosy­

novitis(Table 3).

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Fig. 3. Normal sized extensor tendons of the wrist are surrounded by l1uid(arrows) within common synovial sheath.

The sonographic findings of non-tenosynovitis

cases are listed on table 4

The overall diagnostic accuracy of this series was

81 . 1 % and the only single sonographic finding- l1uid

collection-was statistically significant for the

diagnosis of tenosynovitis.(p<O.05 , Table 5) Other

single findings were not statistically significant for

the diagnosis .(All P>O .25) And also no combination

of sonographic finding was significan t.

Table 3. Sonographic Findings of Tenosynovitis Group

Gwy Suk Seo , et al : Sonographic Characterization of Tenosynovitis

Fig. 4. A longitudinal sonogram of the Achilles tendon shows hypoechoic area with multiple calcific dots(ar­rowheads).

DISCUSSION

Many tendon abnormalities go undetected or go

neglected without call for medical advice . However ,

tendons are a very common site of injury. Inflam­

matory conditions are the second most common

category of tendon abnormality. Tendons are

Patient Fibrillar* * Fluid Swelling Margin ‘ Echo*** Calcification

+ + 2

3

4

5

6

7

8

9

m U

u m M

mu

m n

mω

+

+

+

+ + +

+ +

+ +

+

+

+

+

+

+

+ + +

+

+

+ +

+

* ( +); well defined margin of tendon * *( + ); preserved fibrillar pattern of tendon * * * ( + ); change of echo texture of lesion

+ +

+

+

+ +

+

+ +

+

+ +

+ +

+ +

+ +

+ + + +

+ +

+ + + +

+ +

+

+ +

+

+

낌

Journal of Korean Radi이 ogical Society 1992 ; 28 (2) : 275~280

Table 4. Sonographic Findings of Non-Tenosynovitis Group

Calcification Fluid Echo*** Fibrillar ‘ • Margin* Swelling Patient

+ + +

+

+ + +

+

F +

+

l

2

3

4

5

6

7

8

9

+ +

+

+

+

+ +

+

+ + + +

*( +) ; well defined margin of tendon * *( +); preserved fibrillar pattern of tendon

* * • (+); change of echo texture of lesion

+

Table 5. US findings vs their Significance in Tenosynovitis

P valve specificity (e)

sensitivity (e)

False

(-) False

( + )

True (-)

True (+)

US finding

>0 .50

>0 .50

>0.75

>0.25

<0.05

>0 .50

33.3

22.2

33.3

44.4

100.0

100.0

83.3

6 1.1

72.2

55.6

50.0

16.7

3

7

5

8

9

샌

6

7

6

5

0

0

3

2

3

4

9

9

mω n

퍼 m

9

3

Swelling Margin*

Fibrillar* * Echo***

Fluid

Calcification

*( +) ; well defined margin of tendon * ‘ ( +); preserved fibrillar pattern of tendon

* * *( +) ; change of echo texture of lesion

quickly into adjacent tendinous structures especial­

ly in hands where common synoviaJ sheath envelops

the deep and superficiaJ flexor tendons at the finger

leveI(6). Tenosynovitis is not only the result ofminor

or vigorous trauma. calcific deposit or infection(7.8).

but is associated with other arthritides such as

rheumatoid arthritis or tuberculosis(8). The concept

of a special form-nodular tenosynovitis is stilI under

controversy. Some regard it as a giant ceIJ tumor of

the tendon sheath and others insist it is a synovial

inflammation(6.7) .

Ultrasonographic examination has been

established method for tendon pathology but its main

application was for tumorous conditions and

traumatic ruture(l -5) . There have been only a smaIJ

number of articIes on tenosynovitis. Jeffrey. J r.

reviewed surgicaIJy confirmed acute tenosynovitis

and the sonographic finding was hypoechoic area sur­

rounding the involved tendon(ll) and a case report

enveloped by a double layered synovial sheath when

they pass through an osseofibrous tunnel such as in

hands and feet(6) . So tendinous inflammation easily

develops into tenosynovitis or vice versa. It spreads

an

Fig. 5. A well-demarcated mass from the flexor tendon of the ha nd has homogeneous echogenicity and calcific foci It was misdiagnosed as benign tumor sonographically.

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Gwy Suk Seo, et al : Sonographic Characterization of Tenosynovitis

by Stephenson shows peritendinous f1 uid with nor­

mal tendons( 12)_ In our series , the main findings were

focal swelling of the tendon with preservation of a

fibrillar pattern , well-defined margin and f1uid collec­

tion. Focal swelling and preserved fibrillar pattern is

of high sensitivity but quite non-specific. In contrast ,

f1uid collection is of statistical significance in diagnos­

ing tenosynovitis

In seven cases which had initial manifestation of

palpable mass , the suspected mass proved to be

swelling of the tendon in four cases , f1uid collection

without tendon change in one case , focal swelling of

the tendon in one cases and actual mass discovery

sonographicallY in one case. The last case was

misdiagnosed preoperatively(Fig. 5) . In another case

with complete disruption of the fibrillar pattern ,

tenosynovitis could not be suggested. There were two

cases whose ultrasonographic dignosis was

tenosynovitis , but were confirmed to be fibroma and

ganglion at operation. Likewise , focal swelling

without f1uid colleciton of the tendon remains a

diagnostic pitfall , which says again that f1uid colle­

tion is criterion of high specificity but low sensitivity

In conc1usion , ultrasonography is useful in

diagnosing tenosynovitis and the major specific

sonographic finding is f1uid collection. But differen­

tiation between nodular tenosynovitis and benign

tumor by ultrasonography is still problematic.

REFERENCES

1. Khaleghian R. Tonkin LJ , De Geus JJ , Lee JPK.

Ultrasonic examination of the flexor tendons of th e

fingers . J Clin Ultrasound 1984;12:547-551

2. Dillehay GL , Deschler T , Rogers LF, Neiman HL.

Hendrix RW. The ultrasonographic characterization

of tendonds. Invest Radiol 1984:19:338-341

3. Fornage BD , Schernberg FL , Rilkin MD. U1trasound

exam ination of the hand. Radiology

1985: 155:785-788

4. Blei CL , Nirschl RP , Grant EG. Achilles tendon:US

diagnosis of pathologic conditions. Radiology

1986;159:765-767

5. Harcl‘e HT , Grissom LE , Finkelstein MS. Evaluation

of the musculoskeletal system with sonography.

AJR 1988: 150: 1253-1261

6. Gardner E , Gray DJ , 0 ’ Rahilly R. Anatomy. 4th Ed

Philadelphia:W B Saunders company. 1975;28-29

7. 대한정형외과학회. 정형외과학. 서울 최신의학사， 1982 : 311-315

8. Turek SL. Orthopedics. Principles and their applica­

tion , vol 2. 4th Ed. Philadelphia:Lippincot t,

1984;931-932

9. Juan Rosa i. Ackermann ’s surgical pathology. vol .

7th Ed. S t. Louis:Mosby , 1989;1520-1522

10. Robbins CK. Robbins pathologic bases of disease.

4th Ed. Philadelphia:WB Saunders company ,

1989‘ 1361-1363

11. Jeffrey RB. Jr, Laing FC , Schechter WP , Markison

RE , Barton RM. Acute suppurative tenosynovitis of

th e hand :Diagnosis with US. Radiology

1987; 162:741-742

12. Stephenson CA. Seibert JJ , McAndrew MP , Glasier

CM , Leitheser RE , J r.‘ Iqbal V. Sonographic

diagnosis oftenosynovitis ofthe posterior tibial ten­

don. J Clin U1trasounjd 1990;18: 114-116

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Journal of Korean Rad i이 og ica l Society 1992 ; 28 (2) : 275 "'-'280

<국문 요약 〉

사지 건초염의 초음파 진단

한럼대학교 의과대학 진단방사선과학교실

서귀숙·엄효근 ·이인재·이길우·배상훈·이경환

사지의 건염 혹은 건초염은 드물지 않은 질환이나 비특이적 임상소견으로 인하여 진단이 어렵고 과거에는 거의 영상진

단의 대상에서 제외되어 왔다. 최근 고해상력 초음파검사의 도움으로 이 질환의 수술전 영상진단이 시도되고 있는 바， 저

자들은 건 혹은 건 주위의 병변을 의심하여 초음파 검사를 하였던， 건초염 18예를 포항한 27명의 환자군을 대상으로 역행

적 연구를 시행하여 건초염의 초음파 소견을 관찰하고 각 소견의 진단적 가치에 대하여 검토하였다.

전체적인 진단율은 8L 1%였고 흔한 초음파 소견으로는 건의 국소적 종창이 있고 건의 외연이나 건 섬유의 평행한 배열

이 유지되어 있으며， 병변부위의 에코의 불규칙한 변화， 삼출액 등이 관찰되었으며 이중 단독소견으로는 삼출액만이 건초

염 진단에 、통계적으로 유의한 수치를 나타냈다(p<O.05). 건초염의 진단에 있어서 초음파 검사가 유용하며 단독 소견으로

삼출액이 진단적 가치가 있으나 그 낮은 민감도로 인하여 삼출액을 통반하지 않은 건초염과 양성 종양의 감별에는 초음파

검사만으로는 불충분하다.

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