Sonoanatomy, scanning technique and basic pathology

of

- the Wrist and Hand-

Rita Barros
EULAR Teach the Teachers Ultrasound Course
May 28-29th, Copenhagen
Wrist Standard scans
Dorsal longitudinal scan (radial) - (median) - (ulnar)
 

Dorsal transverse scan (radial) - (median)-(ulnar)

Volar transverse scan Volar longitudinal scan

image Ref 5-P.Barceló.I Iriarte. Ecografía musculoesquelética. Atlas ilustrado. AM Martinez Ruiz, P Barceló Galindez: Ecoanatomia y sistemática exploratória de carpo y mano. Editorial Medica
Panamericana Madrid (2015); ref 6 ; ref 3
 Wrist Dorsal Scans
Radial—Median (Digit 3 aligned) –Ulnar
-Longitudinal (Long axis) scan * Transverse scans Dorsal wrist Structures & pathology  Key features 
In longitudinal scan:
 
RC/IC/DRU joints
D3 alignment)-
SynovitisSynovial cys Radius,  lunate ,
Ligament tears   capitate bonés-
ts /ganglia
Erosions (reference for 
Lesions of triangular RC /Intercarpal joints) 
fibrocartilage complex
  Calcification
Bony lesions (erosions,
osteophytes)
Calcifications

Retinaculum 
In transverse scan:

Extensor Tendons  Lister’s tuercule

Tenosynovitis/ (reference  for ET in

Tendinosis  short axis)
Rheumatoid nodules
Ganglion

Table adapted from both Ref1. Backhaus M et al Ann Rheum Dis 2001;60:641–649; Ref2. Ref2- MJ Kohler Minne (ed) Musculoskeletal Ultrasound in Rheumatology Review. Arnold Ceponis ,
Eugene Y Kissin: Ultrasound of the Hand and Wrist. Springer Nature Switzerland AG (2021);Ref6
Dorsal Wrist Mid-line
Joints

Ref 6
Wrist Dorsal scans
tendons
 

ref 6 ; image ref 6

WRIST – Dorsal Radial Scan
Radial wrist Structures & pathology  Key features 

De Quervain´s tendinosis Tenosynovitis distal radius : First EC at level

(TS)
slightly distal (palpate)
Trapeziometacarpal arthrosis
(rizartrosis) 

Table Ref2
 Ulnar wrist- Dorsal

Images ref 6 Bruin, Table adapted ref 1 and 4

 Palmar Wrist

Synovitis
Tenosynovitis
Morphostructural changes of MN
Ganglion

Images Ref3; Ref4

Hand Dorsal/Palmar (volar) scans
Longitudinal/Transverse
1 Dorsal longitudinal scan
2 Dorsal transverse scan

3 Palmar longitudinal scan

4 Palmar transverse scan (fig 10)

Ref1; images and drawing Ref 5

Hand Dorsal/Palmar (volar)
scans Longitudinal/Transverse
5 Thenar longitudinal scan
6 Thenar transverse scan

7 Hypothenar longitudinal scan

8 Hypothenar transverse scan

Ref 7-Singh JP, Kumar S, Kathiria AV, Harjai R, Jawed A, Gupta V. Thumb ultrasound: Technique and pathologies. Indian J Radiol Imaging 2016;26:386-96.
Finger dorsal scans- Longitudinal and Tranverse
Dorsal finger  Structures & pathology  Key features 

Synovitis (Effusion/proliferation) Normal curvature just proximal to metacarpal head

(not erosion) and feeding vessel 
Sagital bands
Optimize visualization: gel layer visible (“float
probe”
Extensor tendon pathology
(paratenonitis/tendinosis/rupture/luxation)

Synovial cysts /Ganglion

Cartilage thinning/lesion

Bone lesion (erosion, change of the bone

profile, osteophyte)

Articular dislocation

Periarticular lesions: rheumatoid nodules,

crystal deposition, calcinosis

Images ref 4 ; table ref2adapted

MCP sinovitis
double contour,
toPhus
sagital band lesion
 Palmar finger-Longitudinal and tranverse scans
Palmar finger  Structures & pathology  Key features 

Palmar synovitis Attention to the synovial reflection

just proximal to palmar plate
Bone erosion/osteophyte

Flexor tendons 
(tendinosis /tenosynovitis/rupture)

Pulleys 

Palmar plate dammage

Articular dislocation

Ref 2Minne (adapted)Upper Images: Ref1 Lower image Ref 5

 Palmar finger – TS and Synovitis

   
 

Flexor TS at Ph2
Palmar finger scan- TS, Pulleys, cyst

Image Ref 4
 Finger Radial Longitudinal ( Tranverse) scan
Finger Ulnar Longitudinal (Tranverse) scan
Radial/ulnar finger  Structures & pathology  Key features 

Marginal erosions 
Assess collateral ligament origin for cortical erosions
Collateral ligament damage 
Lateral/ ulnar scan
metacarpophalangeal I, II, V
joints)
Radial/ Medial scan
PIP ulnar /Lateral/scan
DIP

Table ref 1+ ref2 adapted ; image ref 4

Conclusion
High resolution US is useful for the diagnosis and monitoring of pathology of the wrist and hand
in rheumatology; it is also useful to guide diagnostic and therapeutic procedures.

Bibliography (Images /Figures):

Ref 1-Backhaus M et al Ann Rheum Dis 2001;60:641–649

 
Ref 2- MJ Kohler Minne (ed) Musculoskeletal Ultrasound in Rheumatology Review. A Ceponis, EY Kissin: Ultrasound of the Hand and Wrist. Springer
Nature Switzerland AG (2021)
Ref 3- JM Daniel , WW Dexter (eds) Basics of Musculoskeletal Ultrasound. JJ Albano: “Wrist” .Springer Nature Switzerland AG (2021)
Ref 4 JM Daniel , WW Dexter (eds) Basics of Musculoskeletal Ultrasound. Matthew C Bayes: “Hands and Fingers”. Springer Nature Switzerland AG
(2021)
Ref 5-P Barceló, I Iriarte. Ecografía musculoesquelética. Atlas ilustrado. AM Martinez Ruiz, P Barceló Galindez: Ecoanatomia y sistemática
exploratória de carpo y mano. Editorial Medica Panamericana Madrid (2015)
Ref 6 -GAW Bruin, WA Schmidt Introductory Guide to Muscleskeletal ultrasound for the Rhreumatologist. 2nd Edition. Bruyn Bohn Stafleu von
Loghum. (2011)
Ref 7-Singh JP, Kumar S, Kathiria AV, Harjai R, Jawed A, Gupta V. Thumb ultrasound: Technique and pathologies. Indian J Radiol Imaging
2016;26:386-96.

Ultrasound images: All US scans images were acquired by the author in clinical practice.

Acknoledgements: Dr.Ana Sofia Pinto for modelling.