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PICTORIAL ESSAY
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 148-151

USG of mass in hand and wrist


1 Department of Radiology, University Hospitals of Leicester, Leicester; Kettering General Hospital, Kettering, United Kingdom
2 Department of Radiology, University Hospitals of Leicester, Leicester, United Kingdom

Date of Web Publication15-Oct-2012

Correspondence Address:
Rajesh Botchu
11 Jackson Way, Kettering, NN15 7DL
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.102437

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  Abstract 

Ultrasound (USG) is a simple, dynamic, and cost effective modality for investigation of a lump in the hand and wrist. We present sonographic findings of various lumps of the hand and wrist.

Keywords: Hand, lump, Ultrasound


How to cite this article:
Botchu R, Bhatt R. USG of mass in hand and wrist. J NTR Univ Health Sci 2012;1:148-51

How to cite this URL:
Botchu R, Bhatt R. USG of mass in hand and wrist. J NTR Univ Health Sci [serial online] 2012 [cited 2019 Mar 23];1:148-51. Available from: http://www.jdrntruhs.org/text.asp?2012/1/3/148/102437


  Introduction Top


Musculoskeletal sonography has exponentially increased during the last decade. USG is simple, cheap, and easily accessible. USG enables to interrogate the tendons, nerves, ligaments, and synovium dynamically. [1],[2],[3],[4],[5],[6],[7] One needs to familiarize with the morphological anatomy and normal variants. Doppler USG (power and color) enables to analyze the vascularity of the lump. USG can be used in evaluation of both acute and chronic pathologies. [1],[2],[3] During sonographic analysis of lump, comparison with the contralateral hand and wrist may be useful. USG should be the first line of investigation for a lump in hand and wrist. We present the sonographic findings of lumps of hand and wrist.


  Materials and Methods Top


USG of the hand and wrist is performed with a high-frequency 13 and 15 MHz probe (Philips, iU22, (Philips Medical Systems, DA Best, The Netherlands)). The hand and wrist and scanned via volar and dorsal approaches. The tendons, nerves, and ligaments are examined dynamically by stressing the wrist and hand. Sonography is also performed during active and passive movements of the joint and tendon concerned which enables to decipher subluxation and dislocation of the tendons and exaggerated the tears. The lump is scanned in longitudinal and axial planes. Doppler (color and power) is used to analyze the vascularity of the lump and adjacent tissues. We present the USG findings of various lumps of hand and wrist.

Ganglion

Ganglion is seen as anechoic, well-defined lesion which is intimately related to the joint or tendon sheath. These can have lobulated appearances with septations and may contain debris. A communication between the ganglion and joint is demonstrated in a few cases. Posterior acoustic enhancement is commonly associated with moderate to large ganglion. [1],[4],[5]

These are avascular lesions, though minimal peripheral vascularity could be seen on Doppler in some subjects [Figure 1]. The added advantage of sonography is it allows the guidance of needle placement for optimum instillation of steroids or aspirations. [1]
Figure 1: Ganglion – longitudinal and axial USG of the wrist showing hypoechoic lesion deep to extensor tendons

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Tenosynovitis

In patients with tenosynovitis, the involved tendon is hyperemic (on Doppler USG) with peritendinous anechoic fluid [Figure 2]. USG enables to instill steroids, avoiding the tendon hence significantly decreasing the morbidity. [1]
Figure 2: Tenosynovitis – Transverse USG shows an edematous extensor carpi ulnaris with fluid and increased signal on Doppler (blue arrow), normal extensor digitorum for comparison (red arrow)

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Tendinopathy

The tendon is enlarged with loss of normal fibrillar pattern in tendinopathy. Calcification and cystic degeneration can also be seen in tendinopathy. Doppler USG may demonstrate some increased vascularity in the involved segment of the tendon.

Tendon subluxation

The flexor and extensor tendons are held to the bone with pulleys and retinacula. Injury to the pulleys and retinacula may result in dislocation or subluxation of tendon. Dynamic USG and USG during stressing, the involved joints help to analyze this effectively.

Foreign body granuloma

Foreign bodies are noted as hyperechoic lesions with posterior acoustic enhancement. Granulation tissue and fluid may be seen adjacent to the foreign body which is noted as ill-defined anechoic or hypoechoic areas [1] [Figure 3].
Figure 3: Foreign body – Longitudinal and transverse USGhyperechoic foreign body in the volar aspect of the middle finger with adjacent granulation tissue (long arrows)

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Neuroma

Neuromas are seen as well-defined hypoechoic lesions with an entering nerve and exiting nerve. Knowledge of the course of the nerves of hand and demonstration of entering and exiting nerves enables one to clinch the diagnosis [6] [Figure 4].
Figure 4: Schwannoma – Transverse and longitudinal USG- mixed echogenic lesion in relation to ulnar nerve with entering and exiting nerves (small arrows) with increased vascularity on Doppler USG

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Giant cell tumors

These demonstrated varied appearances (hypoechoic, hyperechoic, or mixed) with increased vascularity on Doppler USG. Posterior acoustic enhancement may be seen in some giant cell tumors. These are closely associated with the flexor tendon and flexor tendon sheath [1],[7] [Figure 5].
Figure 5: Giant cell tumor – Longitudinal USG-hypoechoic welldefined lesion anterior to the middle finger flexor tendon with increased signal on Doppler

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Lipomas

The echogenicity of lipomas are quite variable ranging from hyper, hypo to isoechoic which is dependent on relative proportion of fat and water in the lesion. [1],[8] These can be ill- defined or well defined. These are usually avascular and the presence of increased vascularity on Doppler USG should raise the suspicion of malignant transformation [1],[8] [Figure 6].
Figure 6: Lipoma – Longitudinal USG-hypoechoic well-defined lesion with hyperechoic septations (long arrow) within the subcutaneous tissues in relation to volar aspect of the hypothenar eminence

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Pigmented villonodular synovitis

Pigmented villonodular synovitis (PVNS) involves proliferation of synovium which contains hemosiderin and is of unknown etiology. These are seen as hypoechoic intra-articular lesions which demonstrated increased vascularity on Doppler USG. [9] These can cause irregularity of the articular surface (joint erosions).

Hemangioma

Hemangioma is a well-defined mixed echoic lesion which has intense vascularity on Doppler USG. Phleboliths which are seen as hyperechoic lesions with post acoustic shadowing help to clinch the diagnosis. These are predominantly intramuscular containing low flow vessels [1] [Figure 7], and [Figure 8].
Figure 7: Hemangioma – Longitudinal and transverse USG- mixed echogenic well-defined lesion within the subcutaneous tissue overlying the 3rd MCPJ with increased signal on Doppler

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Figure 8: Pseudoaneurysm – Transverse USG-ectatic radial artery with large pseudoaneurysm

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Osteophytes

In osteoarthritis, there is irregularity of the involved joint with anechoic fluid. Osteophytes are seen as hyperechoic lesions with posterior acoustic shadowing. Comparison with adjacent joints may be helpful. These can be quite prominent especially at the dorsal bases of the 2 nd and 3 rd metacarpals known as the carpal boss [Figure 9].
Figure 9: Carpal boss – Longitudinal USG showing prominent dorsal 2nd and 3rd carpometacarpal joints

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Accessory muscles

Accessory muscles of the hand are additional muscles which are seen as normal variants. These can be either due to supernumerary muscles or due to anomalous origin of muscle. One needs to acquaint oneself with these as these are usually overlooked. These can be asymptomatic. Symptomatic presentations include palpable masses or due to mass effect. [10] The accessory muscles in the hand include accessory digiti minimi, accessory flexor digiti minimi, flexor carpi radialis vel profundus, accessory extensor carpi radialis, and extensor digitorum brevis manus. These can be misinterpreted as ganglion or carpal boss [Figure 10].
Figure 10: Accessory palmaris longus muscle – Longitudinal (a) and axial (b) US images of right wrist showing anomalous palmaris longus muscle (*). Sagittal (d) and axial (e) proton density images of the wrist showing anomalous palmaris longus muscle (*)

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  Conclusion Top


We have presented the USG features of various lumps and bumps of the hand. Familiarity with this is essential to decrease morbidity.

 
  References Top

1.Bianchi S, Della Santa D, Glauser T, Beaulieu JY, van Aaken J. Sonography of masses of the wrist and hand. AJR Am J Roentgenol 2008;191:1767-75.  Back to cited text no. 1
[PUBMED]    
2.Garcia J, Bianchi S. Diagnostic imaging of tumors of the hand and wrist. Eur Radiol 2001;11:1470-82.  Back to cited text no. 2
[PUBMED]    
3.Jacob D, Cohen M, Bianchi S. Ultrasound imaging of non-traumatic lesions of wrist and hand tendons. Eur Radiol 2007;17:2237-47.  Back to cited text no. 3
[PUBMED]    
4.Wang G, Jacobson JA, Feng FY, Girish G, Caoili EM, Brandon C. Sonography of wrist ganglion cysts: Variable and noncystic appearances. J Ultrasound Med 2007;26:1323-8.  Back to cited text no. 4
[PUBMED]    
5.Spence LD, Fitzgerald E. The role of ultrasound in the diagnosis of ganglion cysts. Postgrad Med J 1995;71:206-7.  Back to cited text no. 5
[PUBMED]    
6.Stuart RM, Koh ES, Breidahl WH. Sonography of peripheral nerve pathology. AJR Am J Roentgenol 2004; 182:123-9.  Back to cited text no. 6
[PUBMED]    
7.Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: Analysis of sonographic findings. AJR Am J Roentgenol 2004;183:337-9.  Back to cited text no. 7
[PUBMED]    
8.Inampudi P, Jacobson JA, Fessell DP, Carlos RC, Patel SV, Delaney-Sathy LO, et al. Soft-tissue lipomas: Accuracy of sonography in diagnosis with pathologic correlation. Radiology 2004;233:763-7.  Back to cited text no. 8
[PUBMED]    
9.Yang PY, Wang CL, Wu CT, Wang TG, Hsieh FJ. Sonography of pigmented villonodular synovitis in the ankle joint. J Clin Ultrasound 1998;26:166-70.  Back to cited text no. 9
[PUBMED]    
10.Sookur PA, Naraghi AM, Bleakney RR, Jalan R, Chan O, White LM. Accessory muscles: Anatomy, symptoms, and radiologic evaluation. Radiographics 2008; 28:481-99.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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   Abstract
  Introduction
   Materials and Me...
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