Diagnostic Imaging of the Hand [1 ed.] 9781588904539

Table of contents :
Diagnostic Imaging of the Hand
T able of Contents
Abbreviations
XVIII Abbreviations
XIX
Imaging Techniques of the Hand
1 Projection Radiography: General Information and Positioning Techniques .
1 Projection Radiography: General Information and Positioning Techniques
General T echniques f or R a dio logic Diagnosis of Hand Abnormalities
Examining Instruments
A uxiliary Materials
R adiation Protection Measures
R ecording Systems and Exposure Parameters
P eculiarities in Childhood
Special Examination Techniques
Special Imaging Techniques
R adiographs of the Entire Hand
R adiographs of the Wrist
The Scaphoid Quartet Series
R adiographs of the Other Carpal Bones
R adiological Stress Views of the Carpus and Thumb
R adiographs of the Metacarpal R egion
R adiographs of the Thumb and Finger
2 Special Radiographic Procedures
Digital Radiographic Procedures
Digital Luminescence R adiography (DLR)
The Principle
Direct Radiography with Flat Detectors
T echnical Procedure
Indications
The Principle
T echnical Procedure
R adiography with Mammography Films 15
Image-intensifying R adiography
Indications
The Principle
T echnical Procedure
Indications
R a diography with Mammography Films
The Principle
T echnical Procedure
Indications
T e c hniques in Magnification Radiography
Magnification Radiography with Mammography Equipment
The Principle
T echnical Procedure
Magnification Radiography with the DIMA Technique
The Principle
T echnical Procedure
Indications
Low-kilovoltage Technique
The Principle
T echnical Procedure
Indications
Normal Anatomy and Pathomorphology
Conventional Tomography
The Principle
T echnical Procedure
Indications
Cineradiography
The Principle
T echnical Procedure
Cineradiography 21
Indications for Carpal Cineradiography
F urther Reading
3 Arthrography
Anatomical Considerations
Arthrography of the Large Joint Spaces
Examination Technique
Multicompartment Arthrography
Arthrography of the Large Joint Spaces 25
Documentation
MR Arthrography and CT Arthrography
C ommunicating Pathways
U A unidirectional defect (Fig. 3. 3 a–c ) i s a n incomplete
V ariants and Lesions
Arthrography of the Small Joint Spaces 27
Arthrography of the Small Joint Spaces
Arthrography of the Pisotriquetral Joint
Arthrography of the Saddle Joint of the Thumb
Arthrography of the Finger Joints
Indications and Assessment
Indications and Assessment 29
F urther Reading
4 Arthroscopy
Necessary Equipment
Arthroscopic Access 31
Arthroscopic Access
Normal Arthroscopic Findings
The Radiocarpal Joint (Fig. 4. 3 )
Indications for Diagnostic Arthroscopy 33
The Distal Radioulnar Joint
The Midcarpal Joint
Indications for Diagnostic Arthroscopy
Indications for Therapeutic Arthroscopy
Contraindications and Complications
F urther Reading
C ontraindications and Complications 35
5 Arteriography
Anatomy and Variants of Hand Arteries
F orearm Arteries
Arteries in the Palm
Arteries of the Finger
Arteries of the Dorsum of the Hand
Diagnostic Imaging
Catheter Angiography
Prerequisites
Arterial Accesses
Puncture and Catheter Materials
C ontrast Agents and Their Application
P harmacoangiography
P hlebography
Image Acquisition in Digital Subtraction Angiography
Examination Risks
MR Angiography
P erequisites
T ype of Sequence, Sequence Parameters
C ontrast Medium and Its Application
Arrival of the Contrast Medium
Maximal Intensity Projection
Specific Differential Indications
F urther Reading
6 Skeletal Scintigraphy
Physical-Technical Foundations
2 MIN. P .I. Q R / L = 2 . 8
2 HOURS P .I. Q R/L = 7.6
Biological Foundations
Biological Foundations 47
F a ctors Influencing Scintigraphic Images
Indications for Skeletal Scintigraphy 49
P ALMAR
2 WEEKS
P ALMAR
4 WEEKS
P ALMAR
7 WEEKS
P ALMAR
12 WEEKS
Indications for Skeletal Scintigraphy
Screening and staging in polytrauma, systematic skeletal and joint di
7 D A Y S AFTER TRAUMA
2 MIN P .I. Q L/R = 1.2
2 HOURS P .I. Q L/R = 2.1
Indications for Skeletal Scintigraphy 51
2 MIN. P . I.
P ALMAR
P LANTAR
3 H O U R S P . I .
P ALMAR
P LANTAR
Scintigraphic Peculiarities among Children
Examination Technique in Children
Scintigraphic Peculiariti es among Children 53
P attern of Tracer Accumulation in Skeletal Scintigraphy
F urther Reading
7 Ultrasonography
P h y sical Principle
B-scan Ultrasonography 55
B-scan Ultrasonography
Doppler Ultrasonography and Color-coded Doppler Ultrasonography
S pecial Prerequisites for Ultrasonographic Examination of the Small Parts of
Special Prerequisites for Ultrasonographic Examination of the Small Parts of
Normal Ultrasonographic Findings
Examination Procedure
7. 4 a, b , 7. 5 a, b ).
Examination Procedure 59
Indications
F urther Reading
8 C omputed Tomography
General Principle of CT
Spiral CT Technique
Imaging Parameters
Spatial Resolution
Density Resolution
Examination Techniques for CT of the Hand 65
Artifacts in CT Imaging
Out-of-Field Beam-Hardening Artifacts
Limitation of the Spatial Bandwidth
P artial-Volume Effect
Examination Techniques for CT of the Hand
P o sitioning
P lanning Images
A cquisition Parameters and Dose
Image Computation
Image Postprocessing from CT Volume Datasets
Multiplanar Reconstruction (MPR)
Three-dimensional Surface Reconstruction
V olume Rendering (VR)
Maximal Intensity Projection (MIP)
Normal Anatomy with Evaluation of the Slice Planes
CT Arthrography
T echnical Procedure
CT Arthrography 71
Interpretation and Clinical Applicability
Osteoabsorptiometry
T echnical Procedure
Interpretation and Clinical Applicability
Indications
F urther Reading
9 Magnetic Resonance Imaging
MR Imaging Basics
Pulse Sequences
Spin-Echo Technique
F ast Spin-Echo Technique
Inversion Recovery Technique
Gradient-Echo Technique
GRE Sequences with Dephasing o f the Transverse Magnetization
GRE Sequences with Rephasing of the Transverse Magnetization
GRE Sequences of Special Design
DESS Sequence
MEDIC Sequence
CISS Sequence
VIBE Sequence
F ast and Ultrafast GRE Sequences
Three-dimensional Technique (3D Technique)
F a t -Saturation Techniques
Diagnostic Utility
C ontrast Medium 81
P arallel Imaging
Contrast Medium
Contrast Medium Effects
MR Arthrography
Contrast Medium A dministration for Standard Investigations
Contrast-Enhanced MR Angiography
P l anning of the Examination Volume 83
Nephrogenic Systemic Fibrosis (NSF)
Dynamic MR Imaging of the Carpus
Planning of the Examination Volume
R ecommendations for MR Imaging Sequences for Examining the Hand
Sequence Protocols
MR Imaging Protocol in Scaphoid Trauma (Table 9. 8 )
Basic MR Imaging Protocol
MR Imaging Protocol in Carpal T r auma
MR Imaging Protocol in Nonunion of the Scaphoid
MR Imaging Protocol in Lesions of the Ligaments and the Tri angular Fibrocar
MR Imaging Protocol in Carpal Osteonecrosis (Lunate Osteonecrosis) (Table 9
MR Imaging Protocol for Identification of Ganglia
MR Imaging Protocol in Arthritic Joint Diseases
MR Imaging Protocol for Diagnosis of Soft-tissue Tumors and Bone Tumors (Ta
Normal MR Anatomy of the Hand
Muscle Compartments and Neurovascular Bundles o f the Forearm (Fig.9. 7 )
Osseous Structures of the Hand (Fig. 9. 8 )
Carpal Ligaments and the Triangular Fibrocartilage C omplex (TFCC) (Fig. 9.
C ontents of the Carpal Tunnel (Fig. 9. 9 a, b )
Guyon’s Canal (Fig. 9. 9 a, b )
Extensor Tendons (Fig. 9. 9 a, d )
The Thenar Region (Fig. 9. 10 b )
The Palmar Canal and the Metacarpus (Fig. 9. 10 a, c )
Hypothenar Region (Fig. 9. 10 b )
Thumbs and Fingers (Figs. 9. 11 and 9. 12 )
F urther Reading
Anatomic and Functional Prerequisites f or Diagnostic Imaging of the Hand
10 Carpal Ligaments
F undamental Anatomy
Interosseous Ligaments
R adioscapholunate (RSL) Ligament, Radioscaphoid (RS) Ligament, and Radioluna
Scapholunate Ligament (SLL)
L unotriquetral Ligament (LTL)
Capitohamate Ligament (CHL)
P almar V-shaped Ligaments
Ligaments of the “Proximal V”
R adiolunotriquetral Ligament (RLTL)
Ulnolunate Ligament (ULL) and Ulnotriquetral Ligament (UTL)
T riangular Fibrocartilage Complex (TFCC)
Ligaments of the “Distal V”
R adioscaphocapitate Ligament (RSCL) and Scaphocapitate Ligament (SCL)
Scaphotrapeziotrapezoid Ligament (STTL)
Arcuate (Triquetrocapitoscaphoid) Ligament (TCSL)
Ligaments of the “Dorsal V”
Dorsal Radiotriquetral Ligament (DRTL)
Dorsal Intercarpal Ligament (DICL)
Extensor Retinaculum
Carpal Collateral Ligaments
R adial Collateral Ligament (RCL)
Ulnar Collateral Ligament (UCL)
P a thoanatomical Principles
for midcarpal instability .
Diagnostic Imaging
Magnetic Resonance Imaging
Scapholunate Ligament (SLL)
L unotriquetral Ligament (LTL)
R adioscapholunate Ligament (RSLL), R adioscaphoid Ligament (RSL), and Radiol
Extrinsic Ligaments
R adial Collateral Ligament (RCL)
R adioscaphocapitate Ligament (RSCL)
R adiolunotriquetral Ligament (RLTL)
Ulnolunate ligament (ULL) and ulnotriquetral ligament (UTL)
T riquetrocapitoscaphoid (“Arcuate”) Ligament (TCSL)
Dorsal Radiotriquetral Ligament (DRTL)
Dorsal Intercarpal Ligament (DICL)
Extensor Retinaculum
Arthroscopy
Arthrography
11 T r iangular Fibrocartilage Complex
F undamental Anatomy
T riangular Fibrocartilage (TFC)
P almar Radioulnar Ligament (PRUL) and Dorsal Radioulnar Ligament (DRUL)
Meniscus Homologue (MH)
Ulnolunate Ligament (ULL)
Ulnotriquetral Ligament (UTL)
T endon Sheath of the Extensor Carpi Ulnaris (ECU) Muscle
Ulnar Collateral Ligament (UCL)
P a thoanatomic Principles
Diagnostic Imaging
Magnetic Resonance Imaging
Examination Techniques
T riangular Fibrocartilage (TFC)
P almar Radioulnar Ligament (PRUL) and Dorsal R adioulnar Ligament (DRUL)
Meniscus Homologue (MH)
Ulnolunate Ligament (ULL) and Ulnotriquetral Ligament (UTL)
T endon Sheath of the Extensor Carpi Ulnaris (ECU) Muscle
Ulnar Collateral Ligament (UCL)
Ulnar (Prestyloid) Recess
Arthroscopy
R adiographic Diagnosis
Computed Tomography
Arthrography
12 Carpal Morphometry and Function
Morphometry and Function of the Distal Forearm
Joint Angle of the Distal Radius Segment
R elative Lengths of the Radius and the Ulna
R adioulnar Translation
R o tation of the Forearm (Pronosupination)
Morphometry and Function of the Carpus
R adiographic Carpal Arches
Carpal Angles
Carpal Height
Carpal Movement Planes and Axes
Ulnar Deviation of the Carpus
Flexion and Extension
R adial and Ulnar Inclination
During ulnar inclination o f the carpus:
Concepts of Carpal Stability and Instability
13 P o stsurgical Radiography
P artial Arthrodesis of the Wrist
Surgery of the Distal Ulna
Surgery for Fractures and Nonunion of the Scaphoid 135
Shortening of the Radius and Ulna
Surgery for Fractures and Nonunion of the Scaphoid
Surgery for Radius Fractures and Corrective Osteotomy of the Radius
Surgery for Carpal Instability, Dislocations, and Dislocation Fractures 137
Surgery for Carpal Instability, Dislocations, and Dislocation F r actures
Surgical Salvage Procedures on the Phalangeal Joints
Surgery of Phalangeal Fractures 139
Surgery of Phalangeal Fractures
Arthrodesis
Soft-Tissue and Callus Distractions 141
Soft-Tissue and Callus Distractions
Surgery of Traumatic Amputations
Surgery of Traumatic Amputations 143
Growth, Normal Variants, and Malformations of the Hand
14 The Growing Skeleton of the Hand
Normal Development of the Skeleton of the Hand
Disturbances in Skeletal Maturation
Disturbances in Skeletal Maturation 147
Legal and Forensic Considerations
E v aluation Methods in Diagnostic Imaging
A ge-dependent Factors
Determination of Skeletal Age
A ge Determination Up to Three Months
A ge Determination after the Third Month of Life
A tlas of Greulich and Pyle
E v aluation Methods in Diagnostic Imaging 149
A tlas of Thiemann and Nitz
Methods According to Tanner, Whitehouse et al.
Determination of the Prospective Mature Body Height
Method According to Bayley and Pinneau
Method According to Tanner, Whitehouse et al.
F urther Reading
15 Normal Variants of the Skeleton and the Soft Tissues of the Hand
Normal Variants of the Skeleton of the Hand
Sesamoid Bones
Coalescence of the Carpals
N o rmal Variants of the Skeleton of the Hand 153
Divided Carpals
A ccessory Carpal Bones
Notches and Depressions in Carpal Bones
V ariants in the Shape of the Lunate
Normal Variants of the Soft Tissues of the Hand
V ariants of the Extrinsic and Intrinsic Muscles
High Division of the Median Nerve
P ersisting Median Artery
Duplication of Tendons and Manifold Tendons
F urther Reading
16 Malformations and Deformities
Diagnostic Imaging
16 M alformations and Deformities 159
C l a s sification
F ailure of Formation
T r ansverse Arrest
Longitudinal Arrest
F ailure of Formation 161
F ailure of Differentiation (Separation) of Parts
Symphalangy
Camptodactyly
C linodactyly
P ollex Flexus
Arthrogryposis Multiplex Congenita
Syndactyly
– Other syndactyly syndromes are acrocephalo dactyly types II–V , Car
Duplication
R adial (Preaxial) Polydactyly
Duplication 169
Ulnar (Postaxial) Polydactyly
Mirror Hand
Central Polydactyly
Overgrowth
Undergrowth 171
Undergrowth
Hypoplasia and Aplasia of the Thumb
Brachydactyly
Constriction-Ring Syndrome
Malformation Syndromes (G e n e r alized Abnormalities) 173
Malformation Syndromes (Generalized Abnormalities)
C lassification
Skeletal Deformities
Skeletal Dysostosis
Skeletal Dysplasia (Osteochondrodysplasia)
C lassification
Diagnostic Imaging
Congenital Sclerosing and Hyperostotic Skeletal Changes
Primary Metabolic Disorders of the Skeleton (Dysostosis Multiplex)
Osteopoikilosis
Melorheostosis
Other Hyperostotic Anomalies
C lassification
Diagnostic Imaging
Differential Diagnosis
Injuries of the Hand and Traumatic Sequelae
17 T r auma of the Distal Forearm
A c ute Fractures and Dislocation Fractures of the Distal Forearm
C l a s sification
The Fernandez Classification
U T ype I fractures are bending fractures of the metaphysis
U T ype II fractures are shearing fractures of the joint sur f ace.
F rykman Classification
C omprehensive Classification of Fractures (AO/ASIF Classification)
Aitken’s and Salter’s Classification
Anatomic Foundations
Diagnostic Imaging
R adiographic Diagnosis
Ultrasonography
Magnetic Resonance Imaging
Arthroscopy
M alunion of Distal Radius Fractures 195
Malunion of Distal Radius Fractures
T reatment Options
Diagnostic Imaging
R adiography
C omputed Tomography
Magnetic Resonance Imaging
Arthroscopy
Nonunion after Distal Radius Fractures
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Dislocations in the Dis t al Radioulnar Joint 197
Dislocations in the Distal Radioulnar Joint
C omputed Tomography
Arthroscopy
Differential Diagnosis
F urther Reading
18 Lesions in the Ulnocarpal Compartment
L e sions of the Triangular Fibrocartilage Complex
Anatomic Abnormalities and Clinical Symptoms
C l a s sification
C lass I: Traumatic Lesions
C lass II: Degenerative Lesions
Diagnostic Imaging
Magnetic Resonance Imaging
MR Imaging Techniques
( MR arthrography ).
MR Imaging Results
T r aumatic TFCC Lesions in MR Imaging
Degenerative TFCC Lesions in MR Imaging
Arthroscopy
Arthrography
Examination Technique
Arthrographic Findings in the TFCC
Arthrographic Morphology of TFCC Lesions
Arthrographic Localization of TFCC Lesions
Diagnostic Radiography
Ulnocarpal Impaction Syndrome (Ulnolunate, Ulnolunotriquetral) 213
C omputed Tomography
Ulnocarpal Impaction Syndrome (Ulnolunate, Ulnolunotriquetral)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Diagnostic Radiography
Magnetic Resonance Imaging
Arthroscopy
Differential Diagnosis
Therapeutic Options
19 F r actures of the Scaphoid
P a thophysiology and Clinical Symptoms
S pecial Considerations in Childhood 219
Special Considerations in Childhood
Diagnostic Radiography
Nuclear Medicine
Magnetic Resonance Imaging
Ultrasonography
Differential Indications
Differential Diagnosis
Therapeutic Options
20 Scaphoid Nonunion
P a thogenesis and Clinical Symptoms
P a thogenesis and Clinical Symptoms 231
not, stable (tight) nonunion is differentiated from unsta ble nonunio
Diagnostic Imaging
R adiography
( SNAC wrist ).
C omputed Tomography
Magnetic Resonance Imaging
Differential Diagnosis
P ALMAR Q = 3.7
P ALMAR Q = 1.8
P ALMAR Q = 3.8
5 D A Y S
11 D A Y S
4 WEEKS
T h e r a peutic Options and Posttherapeutic Diagnosis 241
Therapeutic Options and P o sttherapeutic Diagnosis
U R e section o f the r adial styloid process (styloidectomy)
Diagnostic Strategy
F urther Reading
Diagnostic Strategy 243
21 F r actures of the Carpus Excluding the Scaphoid
General Pathoanatomy and Clinical Symptoms
General Information on Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Ultrasonography
S pecial Patterns of Injury
F r actures of the Triquetrum
C omputed Tomography
F r actures of the Pisiform
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
F ractures of the Lunate 249
F r actures of the Lunate
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Tomography
F ractures of the Capitate 251
F r actures of the Capitate
U A classic combination injury is the so-called scaphoid capitate fr
Diagnostic Imaging
R adiography
C omputed Tomography
Magnetic Resonance Imaging
F r actures of the Hamate
P a thoanatomy and Clinical Symptoms
R adiography
F ractures of the Hamate 253
Magnetic Resonance Imaging
F r actures of the Trapezium
P a thoanatomy and Clinical Symptoms
F ractures of the Trapezoid 255
Magnetic Resonance Imaging
F r actures of the Trapezoid
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Combined Carpal Fractures
Diagnostic Imaging
R adiography
C omputed Tomography
Magnetic Resonance Imaging
Special Features of Carpal Fractures in Children
Differential Diagnosis
Therapeutic Options
22 Carpal Dislocations and F r acture-Dislocations
P a thoanatomy and Clinical Symptoms
C l a s sification
C arpal Dislocations and Fracture-Dislocations 261
C omputed Tomography
Magnetic Resonance Imaging
P attern of Injury
P e rilunate and Lunate Dislocations
P e rilunate and Lunate Dislocations 263
P e rilunate Fracture-Dislocations
T r ansscaphoid Perilunate F r acture-Dislocation
(de Quervain)
P erilunate Dislocations with Other Accompanying Fractures
P e rilunate Fracture-Dislocations 265
Scaphoid-Capitate Fracture Syndrome (Fenton)
Axial Dislocations and Fracture-Dislocations 267
Axial Dislocations and Fracture-Dislocations
Therapeutic Options
F urther Reading
23 Carpal Instability
P a thoanatomy and Clinical Symptoms
C l a s sification
Diagnostic Imaging
R adiography
Cineradiography
Arthrography
Magnetic Resonance Imaging
Arthroscopy
F orms of Instability
Dissociative Carpal Instability (CID)
Scapholunate Dissociation (SLD)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Cineradiography
Arthrography
Arthroscopy
Magnetic Resonance Imaging
Lunotriquetral Dissociation (LTD)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Cineradiography
Arthrography
Arthroscopy
Magnetic Resonance Imaging
Therapeutic Options
Nondissociative Carpal Instability (CIND)
P a thoanatomy and Clinical Symptoms
Midcarpal Instability
P a thoanatomy and Clinical Symptoms
R adiocarpal Instability
R adiography
Diagnostic Imaging
Cineradiography
Magnetic Resonance Imaging
C omputed Tomography
Capitolunate Instability
P a thoanatomy and Clinical Symptoms
R adiography
Ulnar Translocation of the Carpus
P a thoanatomy and Clinical Symptoms
Carpal Translocations to the R adial, Palmar, or Dorsal Aspect
P a thoanatomy and Clinical Symptoms
Differential Diagnoses 291
Differential Diagnoses
F urther Reading
24 Carpometacarpal Dislocations and Fracture-Dislocations
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
P attern of Injury
Dorsal Carpometacarpal Dislocations
P almar Carpometacarpal Dislocations
Dorsal Carpometacarpal Fracture-Dislocations
Dorsal Carpometacarpal Fracture-Dislocations 295
P almar Carpometacarpal Fracture-Dislocations
Differential Diagnoses
F urther Reading
25 Metacarpal Fractures
P a thoanatomy and Symptoms
C omputed Tomography
F r a ctures Close to the Base of Metacarpal I 299
Magnetic Resonance Imaging
P attern of Injury
F r actures Close to the Base of Metacarpal I
F r actures of the Bases of the Metacarpals II–V
Subcapital Metacarpal Fractures 301
F r actures of the Metacarpal Shafts
Subcapital Metacarpal Fractures
F r actures of the Metacarpal Heads
Differential Diagnoses
Therapeutic Options
F urther Reading
26 F r actures and Dislocations of the Fingers
Diagnostic Imaging
C omputed Tomography
Magnetic Resonance Imaging
F r a ctures and Dislocations of the Fingers 305
F r acture Types
Extra-articular Fractures
F r actures of the Finger Shafts
F r actures of the Tuberosity of the Distal Phalanx
Intra-articular Finger Fractures
Intra-articular Finger Fractures 307
A vulsion Fractures
Dorsal Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the E
P almar Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the
A vulsion Fractures 309
Dorsal Fracture of the Base of the Middle Phalanx
P almar Fractures of the Bases of the Middle and Distal Phalanges
P ediatric Fractures of the Fingers
Finger Dislocations
Finger Dislocations 311
F r acture-Dislocations of the Fingers
Differential Diagnosis
Therapeutic Options
F urther Reading
Diseases of the Hand Caused by Local or Systemic Degeneration
32 Algodystrophy (Reflex Dystrophy, Complex Regional Pain Syndrome Type I) .
27 Osteoarthritis
Diagnostic Imaging
R adiography
O steoarthritis 317
Osteoarthritis of the Finger Joints
Diagnostic Imaging
Osteoarthritis of the Carpal Joints
Osteoarthritis of the Carpometacarpal Joint I (“Rhizarthrosis”)
P a thoanatomy and Clinical Symptoms
Osteoarthritis of the Scaphotrapeziotrapezoid Joints (STT Osteoarthritis)
P a thoanatomy and Clinical Symptoms
Osteoarthritis of the Pisotriquetral Joint
Osteoarthritis Associated with Carpal Collapse
(SLAC Wrist and SNAC Wrist)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Osteoarthritis of the Distal R adioulnar Joint
S pecial Forms of Osteoarthritis of the Hand 325
Special Forms of Osteoarthritis of the Hand
Inflammatory (Erosive) Osteoarthritis
Diagnostic Imaging
P a thoanatomy and Clinical Symptoms
Combined Degenerative- Rheumatoid Osteoarthritis
P a thoanatomy and Clinical Symptoms
C hondrocalcinosis (Pseudo gout, CPPD Deposition Disease)
Diagnostic Imaging
Hemochromatosis
P a thoanatomy and Clinical Symptoms
Diagnostic Radiography
A cromegaly
Diagnostic Radiography
Differential Diagnosis
Therapeutic Options
28 Enthesopathy
P a thoanatomy and Clinical Symptoms
C l a s sification
Diagnostic Imaging
R adiography
Ultrasonography, CT, and MR Imaging
Predominantly Fibro-ostotic Changes
Endocrine Diseases
Degenerative Diseases
Osteoarthritis
Diabetes Mellitus
Carpal Humps
Predominantly Fibro-ostotic Changes 331
A cromegaly
Hyperparathyroidism
Metabolic Diseases
C hondrocalcinosis, Peritendinitis Calcarea, Alcaptonuria
Hypoparathyroidism
F luorosis
Predominantly Fibro-ostitic Changes
Inflammatory Diseases
R e sorptive Fibro-ostitis
Bacterial Arthritis
Productive Fibro-ostitis
C ombined Forms of Fibro-ostitic L e sions
Rheumatoid and Seronegative Arthritides
28. 4 , 28. 5 ), R e iter disease , and ankylosing spondylitis,
R are Affections of the Fibro osseous Junction
U Progressive o ssifying fibrodysplasia
U The acquired h yperostosis syndrome (AHS)
U F amilial vitamin D-resistant rickets (see Fig. 33. 7 )
Differential Diagnoses
Therapeutic Options
F urther Reading
29 Soft-Tissue Lesions Caused by Overuse and Sports
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
T e ndinosis and Tenosynovitis
U T enosynovitis of the second extensor c ompartment
T endinosis and Tenosynovitis of the Extensor Tendons
T endinosis and Tenosynovitis of the Flexor Tendons
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
T e ndon Rupture 341
T e ndon Rupture
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
Therapeutic Options
Injuries of the Anular Pulleys
Diagnostic Imaging
Injuries of the Anular Pulleys 343
Magnetic Resonance Imaging
Gamekeeper’s Thumb
Diagnostic Imaging
R adiography
Ultrasonography
Magnetic Resonance Imaging
G amekeeper’s Thumb 345
Lesions of the Second to Fifth Metacarpophalangeal Joints
Diagnostic Imaging
R adiography
Bursitis of the Ulnar (Prestyloid) Recess 347
Magnetic Resonance Imaging
Therapeutic Options
Bursitis of the Ulnar (Prestyloid) Recess
Diagnostic Imaging
R adiography
Ultrasonography
Muscular Lesions
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
Therapeutic Options
Differential Diagnosis
F urther Reading
30 Osteonecrosis of the Hand Skeleton
Synopsis
Disease Entities
Lunate Osteonecrosis (Kienböck Disease)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
The more r ecent Lichtman and R o ss’s c lassification
C omputed Tomography
Magnetic Resonance Imaging
U Intact (viable) bone marrow:
U Bone marrow edema and fibrovascular reparative tissue:
U Necrotic bone marrow:
Nuclear Medicine
Diagnostic Algorithm in Lunate Osteonecrosis
Differential Diagnosis
Scaphoid Osteonecrosis (Preiser Disease)
O steonecrosis of the Capitate Head 363
Osteonecrosis of the Capitate Head
Osteonecrosis of the Hook of the Hamate
Osteonecrosis of All Metacarpals (Caffey Disease)
Osteonecrosis of the Metacarpal Heads (Mauclaire Disease)
O steonecroses of the Phalangeal Bases (Thiemann Disease) 365
Osteonecroses of the Phalangeal Bases (Thiemann Disease)
31 Osteopenic Diseases in the Hands
Anatomy and Pathoanatomy
O s t e oporosis
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Procedures for Measuring Bone Density
normal values ( – SD): females
BMC [mg/ml]
age [years]
Therapeutic Options
Rickets/Osteomalacia 371
Rickets/Osteomalacia
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Nuclear Medicine
H yperparathyroidism 373
Hyperparathyroidism
Therapeutic Options
In the renal f orm o f secondary h yperparathyroidism,
R e nal Osteopathy
R adiography
Differential Diagnosis
32 Algodystrophy (Reflex Dystrophy, Complex Regional Pain Syndrome Type I)
P a thogenesis and Clinical Symptoms
Diagnostic Imaging
Nuclear Medicine
Osteodensitometry
P ALMAR
Magnetic Resonance Imaging
Differential Diagnosis
F urther Reading
Diseases of the Hand Related to Systemic Metabolic Diseases
33 Osteopathies Caused by Hormones, Vitamins, Medications, or Toxins
Endocrine Osteopathies
A cromegaly
Hypopituitarism
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
A d renogenital syndrome (AGS)
Hyperparathyroidism
Hypoparathyroidism
Hypothyroidism
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Pseudohypoparathyroidism and Pseudo-pseudohypo parathyroidism
P a thoanatomy and Clinical Symptoms
Hyperthyroidism
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Osteopathies Caused by Hypovitaminosis or Hypervitaminosis
Vitamin D-deficiency Rickets
Diagnostic Imaging
P a thoanatomy and Clinical Symptoms
Vitamin D-resistant Rickets
Hypervitaminosis D
Diagnostic Imaging
Drug-induced and Toxic Osteopathies 389
Vitamin C Deficiency
( Scurvy, Möller–Barlow Disease)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Drug-induced and Toxic Osteopathies
Corticoid Osteopathy
Fluorosis
Diagnostic Imaging
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Prostaglandin Osteopathy
Aluminum Osteopathy
Diagnostic Imaging
Lead Osteopathy
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
F urther Reading
34 Crystal-induced Osteoarthropathies and R e lated Diseases
Gouty Arthritis/Hyperuricemia
Diagnostic Imaging
R adiography
G o u ty Arthritis/Hyperuricemia 393
Ultrasonography
Magnetic Resonance Imaging
Differential Diagnosis
Therapeutic Options
Calcium Pyrophosphate Dihydrate (CPPD) Deposition Disease (Pyrophosphate Arth
P a thoanatomy and Clinical Symptoms
Magnetic Resonance Imaging
F urther Manifestations of CPPD Deposition Disease
C hondrocalcinosis of the Ligaments and the Triangular Fibrocartilage Comple
Destructive Osteoarthropathy of the Wrist
Therapeutic Options
T umorous Chondrocalcinosis
Hydroxyapatite (HA) Deposition Disease (“Acute Calcium Deposition”)
P a thoanatomy and Clinical Symptoms
Hydroxyapatite (HA) Deposition Disease (“Acute Calcium Deposition”) 399
Diagnostic Imaging
R adiography
C omputed Tomography
Magnetic Resonance Imaging
Differential Diagnosis
Hemochromatosis
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Differential Diagnosis
Alkaptonuria (Ochronosis) 401
Wilson Disease
Diagnostic Imaging
Differential Diagnosis
Therapeutic Options
Alkaptonuria (Ochronosis)
Diagnostic Imaging
Differential Diagnosis
Therapeutic Options
O x alosis (Hyperoxaluria)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Differential Diagnosis
Therapeutic Options
F urther Reading
O x alosis (Hyperoxaluria) 403
35 Miscellaneous Osteoarthropathies
Sarcoidosis (Boeck Disease)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Sarcoidosis (Boeck Disease) 405
Magnetic Resonance Imaging
Differential Diagnosis
Therapeutic Options
Neurogenic Osteoarthropathy and Charcot Osteoarthropathy
Diagnostic Imaging
Differential Diagnosis
Therapeutic Options
Hemophilic Osteoarthropathy (“Bleeders’ Joints”) 407
Hemophilic Osteoarthropathy (“Bleeders’ Joints”)
Magnetic Resonance Imaging
Differential Diagnosis
Amyloid Osteoarthropathy
R adiography
Nuclear Medicine
M agnetic Resonance Imaging
Differential Diagnosis
Therapeutic Options
Hereditary Hemoglobinopathies 409
Hereditary Hemoglobinopathies
Nuclear Medicine
Differential Diagnosis
Therapeutic Options
Multicentric Reticulohistiocytosis (Lipoid Arthrodermatitis)
Diagnostic Imaging
Hypertrophic Osteoarthropathy 411
Hypertrophic Osteoarthropathy
Diagnostic Imaging
Differential Diagnosis
Therapeutic Options
R adiation-induced Osteoarthropathy
Diagnostic Imaging
Differential Diagnosis
F o r e i gn-body Synovitis and Arthritis 413
F oreign-body Synovitis and Arthritis
Differential Diagnosis
Synovial Chondromatosis
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Differential Diagnosis
Synovial Chondromatosis 415
F urther Reading
Inflammatory Diseases of the Hand
36 Rheumatoid Arthritis
P a thoanatomy and Clinical Symptoms
36 Rheumatoide Arthritis 419
the American Rheumatism Association (ARA) criteria
Special Forms of Rheumatoid Arthritis
A dult Still Syndrome
F elty Syndrome
Sjögren Syndrome
Caplan Syndrome
Juvenile or Special Forms of Rheumatic Arthritis
Diagnostic Imaging
R adiography
Nuclear Medicine
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
R adiographic Classification of S tages of Rheumatoid Arthritis
Therapeutic Options
F urther Reading
37 Seronegative Spondylarthropathies
Definition
Diagnostic Imaging
R adiography
Seronegative Spondylarthropathies 433
Nuclear Medicine
U Three-phase skeletal scintigraphy with
as immunoscintigraphy with
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
Psoriatic Arthritis (Psoriatic Osteoarthropathy)
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Differential Diagnosis
Psoriatic Arthritis (Psoriatic Osteoarthropathy) 435
R e iter Syndrome (Reiter disease)
P a thoanatomy and Clinical Symptoms
Differential Diagnosis
Therapeutic Options
R e a ctive Arthritis 437
R e active Arthritis
Arthritis with Ankylosing Spondylitis
(Marie–Strümpell Disease, Bechterew Syndrome)
P a thoanatomy and Clinical Symptoms
Differential Diagnosis
Therapeutic Options
Enteropathic Arthritis 439
Enteropathic Arthritis
Differential Diagnosis
Osteoarthropathies Associated with Dermatoses
R adiography
R are Seronegative Arthritides
Behçet Disease
Antibody-deficiency Syndrome
F amilial Mediterranean Fever
Hashimoto Autoimmune Thyroiditis
R are Seronegative Arthritides 441
S t e v ens–Johnson Syndrome
F urther Reading
38 Rheumatic Fever (Poststreptococcal Reactive Arthritis)
P a thoanatomy and Clinical Symptoms
R a diography
Therapeutic Options
F urther Reading
39 Collagenoses
Systemic Lupus Erythematosus (SLE)
P a thoanatomy and Clinical Symptoms
R adiography
Therapeutic Options
Systemic Lupus Erythematosus (SLE) 445
Scleroderma, Progressive Systemic Sclerosis (PSS)
S c l e roderma, Progressive Systemic Sclerosis (PSS) 447
R adiography
Differential Diagnosis
P olymyositis and Dermatomyositis
R adiography
W egener Granulomatosis 449
Therapeutic Options
P anarteritis Nodosa
P a thoanatomy and Clinical Symptoms
Differential Diagnosis
W egener Granulomatosis
Sjögren Syndrome
F urther Reading
40 Infectious Arthritis
P a thoanatomy and Clinical Symptoms
P athways of Infection
The s t ages of so-called soft-tissue signs , c ollateral signs
Nuclear Medicine
Ultrasonography
Arthrography
C omputed Tomography
Infectious Arthritis 453
A c ute Bacterial Arthritis
R adiography
Differential Diagnosis
Therapeutic Options
T uberculosis of the Hand
P a thoanatomy and Clinical Symptoms
R adiography
Leprosy 455
Therapeutic Options
Syphilis
Gonococcal Arthritis
Leprosy
L yme Arthritis
Bilharziosis Arthropathy
Viral Arthritides (Hepatitis B, Rubella, Mumps, Variola, P arvo-B19, Vaccinia
F ungal Arthritis
F ungal Arthritis 457
Inflammatory Diseases of the Bones and Soft Tissues
41 Osteomyelitis
Introduction
R adiography
O steomyelitis 461
Magnetic Resonance Imaging
Disease Entities
Hematogenous Osteomyelitis
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Nuclear Medicine
T u berculous Osteomyelitis 463
T uberculous Osteomyelitis
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Secondary Osteomyelitides
Phalangeal Osteomyelitis
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
C omputed Tomography
P o sttraumatic Osteomyelitis
Bites
P a thoanatomy and Clinical Symptoms
R adiography
Special Forms of Osteomyelitis
Plasma-cell Osteomyelitis, Brodie Abscess, Garré Chronic Sclerosing Osteomye
Osteomyelitides Caused b y Rare Organisms
S pecial Forms of Osteomyelitis 465
C hronic Recurrent Multifocal Osteomyelitis
Therapeutic Options
F urther Reading
42 Infections of the Soft Tissues
Diagnostic Imaging
R adiography
Nuclear Medicine
Infections of the Fingertips and Paronychia 469
Disease Entities
Infections of the Fingertips and Paronychia
P a thoanatomy and Clinical Symptoms
R adiography
Pyogenic Flexor Tenosynovitis
Diagnostic Imaging
Ultrasonography
Deep Space Infections in the Palm 471
Deep Space Infections in the Palm
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Ultrasonography
C omputed Tomography
M agnetic Resonance Imaging
T u berculosis of the Tendon Sheath 473
T uberculosis of the Tendon Sheath
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
A c ute Calcium Deposition
Gangrenous Infection
R adiography
Differential Diagnosis
Therapeutic Options
T umorous and Tumorlike Diseases of the Hand
43 C y stic Bone Lesions
P a thogenesis and Clinical Symptoms
C l a s sification
Bone Cysts with No Pathological Relevance
P o sttraumatic Hemorrhagic C y sts
V asa Nutricia
Necrobiotic Pseudocysts, Idiopathic Carpal Cysts
A v ascular Osteonecroses of the Carpus
Enthesopathic and Arthritic Diseases
Signal Cysts and Arthritic Erosions
Bone Cysts Induced by Infection
Bone Cysts in Systemic Diseases
Metabolic Diseases That Are Associated with Deposits
Hemochromatosis
Gout
X anthomatosis
C hondrocalcinosis (CPPD Deposition)
Amyloidosis
Bone Cysts in Systemic Diseases 483
Bone Cysts in Other Systemic Diseases
“Brown Tumors”
Sarcoidosis
(Osteitis Multiplex Cystices Jüngling)
Gaucher Disease
Fibrous Dysplasia
(Jaffé–Lichtenstein Disease)
Neurofibromatosis type I (Recklinghausen Disease)
T uberous Sclerosis
(Pringle–Bourneville Disease)
C y stic Bone Tumors
Differential Diagnosis
Therapeutic Options
F urther Reading
44 Bone Tumors
R adiography
Arteriography
Nuclear Medicine
Magnetic Resonance Imaging
T umor Entities
Bone Tumors of Chondrogenous Origin
Enchondroma (Chondroma)
P a thoanatomy and Clinical Symptoms
Magnetic Resonance Imaging
Differential Diagnosis
Osteochondroma (Cartilaginous Exostosis)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Differential Diagnosis
C hondrosarcoma
C hondroblastoma, C hondromyxoid Fibroma
P a thoanatomy and Clinical Symptoms
Bone Tumors Originating from Osseous Tissue 491
R adiography
Bone Tumors Originating from Osseous Tissue
Osteoid Osteoma
Diagnostic Imaging
R adiography
C omputed Tomography
Magnetic Resonance Imaging
Bone Tumors Originating from Connective Tissue 493
Osteoblastoma
Diagnostic Imaging
R adiography
C omputed Tomography and Magnetic Resonance Imaging
Osteosarcoma
P a thoanatomy and Clinical Symptoms
have been described in the literature under the t erminol ogy p seud
Bone Tumors Originating from Connective Tissue
Nonossifying Fibroma, Desmoplastic Fibroma
Giant-cell Tumor (Osteoclastoma)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
C omputed Tomography
Malignant Fibrous Histiocytoma (MFH), Fibrosarcoma
Bone Tumors Originating from the Endothelium
Hemangioma
Diagnostic Imaging
C omputed Tomography
Magnetic Resonance Imaging
Arteriography
Hemangioendothelioma, Angiosarcoma
Bone Tumors Originating from the Endothelium 495
Bone Tumors Originating from the Bone Marrow
E wing Sarcoma
Multiple Myeloma (Plasmacytoma), Malignant L ymphoma, Hodgkin Disease, and
Magnetic Resonance Imaging
T umorlike Bone Lesions of the Hand 497
T u morlike Bone Lesions of the Hand
Enostoma, Bone Island
P a thoanatomy and Clinical Symptoms
R adiography
Aneurysmal Bone Cyst
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Magnetic Resonance Imaging
Solitary Bone Cyst (Juvenile Bone Cyst)
R eparative Giant-cell Granuloma
Miscellaneous Joint Diseases and Intraosseous Ganglion Cyst
Magnetic Resonance Imaging
Soft-tissue Tumors with Osseous Infiltration 499
Intraosseous Epidermal Cyst
“Brown Tumor” in Hyperparathyroidism
Other Bone Tumors
Bone Metastases
Soft-tissue Tumors with Osseous Infiltration
45 Soft-tissue Tumors
Diagnostic Imaging
R adiography
Ultrasonography
Soft-tissue Tumors 503
Magnetic Resonance Imaging
Arteriography
T u mors of Cutaneous Origin
E pidermal Inclusion Cyst
P a thoanatomy and Clinical Symptoms
C u taneous Carcinomas
Diagnostic Imaging
T u mors Originating from Connective Tissue
Ganglion Cyst
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Lipoma
P a thoanatomy and Clinical Symptoms
Fibroma
Leiomyoma
P a thoanatomy and Clinical Symptoms
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Diagnostic Imaging
R adiography
Ultrasonography
Magnetic Resonance Imaging
Giant-cell Tumor of the Tendon Sheath (“Xanthoma”)
P a thoanatomy and Clinical Symptoms
A ggressive Fibromatosis (Desmoid Tumor)
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Soft-tissue Sarcomas
Ultrasonography
Magnetic Resonance Imaging
T umors Originating from Blood Vessels and Lymphatic Vessels
Hemangiomas
R adiography
Arteriography
Magnetic Resonance Imaging
Malignant Vascular Tumors
Glomus Tumor
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
L y mphangiomas
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
T u mors Originating from Neural Tissue
Neurinoma (Schwannoma) and Neurofibroma
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Ultrasonography
C omputed Tomography
Malignant Neurinoma (Neurofibrosarcoma)
P a thoanatomy and Clinical Symptoms
Intraneural Fibrolipoma
Diagnostic Imaging
P o sttraumatic Neuroma
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
Therapeutic Options
F urther Reading
Neuropathies and Vasculopathies of the Hand
46 Carpal Tunnel Syndrome
Preliminary Remarks on Anatomy
Pathophysiology and Clinical Symptoms 525
P a thophysiology and Clinical Symptoms
R adiography
Ultrasonography
C omputed Tomography
Magnetic Resonance Imaging
L R
T P
MN MA MN
P o stsurgical Findings
Therapeutic Options
47 Ulnar Tunnel Syndrome (Guyon’s Canal Syndrome)
Preliminary Remarks on Anatomy
P a thoanatomy and Clinical Symptoms
Diagnostic Imaging
R adiography
Ultrasonography
C omputed Tomography
534 47 Ulnar Tunnel Syndrome (Guyon’s Canal Syndrome)
Magnetic Resonance Imaging
Therapeutic Options
F urther Reading
48 V ascular Diseases of the Hand and Fingers
Diagnostic Imaging
Disease Entities
P e ripheral Vascular Disease (Atherosclerosis)
P a thoanatomy and Clinical Symptoms
Findings in DSA and MRA
Peripheral Embolism 537
P e ripheral Embolism
Findings in DSA and MRA
Endangiitis Obliterans (Winiwarter–Buerger Disease)
Findings in DSA and MRA
R aynaud Disease 539
R a ynaud Disease
P a thoanatomy and Clinical Symptoms
Findings in DSA and MRA
Collagenoses and Rheumatoid Arthritis
Scleroderma
(Progressive Systemic Sclerosis)
Findings in DSA and MRA
P anarteritis Nodosa
Lupus Erythematosus
R are Vascular Diseases
Rheumatoid Arthritis
V ascular Injuries and Postsurgical Angiographic Findings
C hronic Vibration Injury
P a thoanatomy and Clinical Symptoms
Findings in DSA and MRA
Hypothenar (Ulnar) Hammer and Thenar Hammer Syndrome
P a thoanatomy and Clinical Symptoms
Findings in DSA and MRA
R adiation-induced Arteriopathies
V ascular Injuries and F alse Aneurysms
Findings in DSA and MRA
r adial artery
aneurysm
r adial artery
P o stsurgical Follow-up
T umors of the Bones and Soft Tissues
C ongenital Malformations
Arteriovenous Malformations 545
Arteriovenous Malformations
Klippel–Trénaunay Syndrome
W e ber Arteriovenous Malformation
Genuine Diffuse Phlebectasia
Servelle–Martorell Arteriovenous Malformation
Maffucci Syndrome
F urther Reading
Differential Diagnostic Tables: Diseases of the Hand
49 C ongenital and Acquired Alterations in Form and Structure of the Epiphys
50 C ongenital and Acquired Alterations in Form and Structure of the Metaph
51 Malformation Syndromes
554 51 M alformation Syndromes
52 Dysplasias (Osteochondrodysplasias)
558 52 Dysplasias (Osteochondrodysplasias)
53 Primary Metabolic Disorders of the Skeleton
Primary Metabolic Disorders of the Skeleton 561
54 Arthritis
55 A cro-osteolyses
A cro-osteolyses 569
56 C y stic Bone Inclusions
572 56 C y stic Bone Inclusions
57 P olyostotic Bone Lesions
574 57 P olyostotic Bone Lesions
Polyostotic Bone Lesions 575
58 Lesions of the Periosteum and Cortical Bone
578 58 L e sions of the Periosteum and Cortical Bone
59 Hyperostoses
H yperostoses 581
60 Osteopenia
Osteopenia 583
61 Soft-tissue Calcifications
586 61 Soft-tissue Calcifications
62 Secondary Raynaud Phenomena
Secondary Raynaud Phenomena 589
Index

Citation preview

Diagnostic Imaging of the Hand Rainer Schmitt, MD Associate Professor of Radiology Department of Radiology Hospital for Cardiovascular Diseases Bad Neustadt an der Saale Germany

Ulrich Lanz, MD Professor of Surgery Department of Hand Surgery Perlach Hospital Munich Germany

With contributions by Wolfgang Buchberger, Georgios Christopoulos, Franz Fellner, Steffen Froehner, Peter Hahn, Thomas Helmberger, Andreas Heuck, Alfred Horwitz, Hermann Krimmer, Gerwin Lingg, Viktor Metz, Karl-Josef Prommersberger, Nicole Reutter, Herbert Rosenthal, Gerhard Schindler, Joerg van Schoonhoven, Sieglinde Spindler-Thiele, Joerg Spitz, Axel Staebler

1160 illustrations

Thieme Stuttgart · New York

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IV Library of Congress Cataloging-in-Publication Data Bildgebende Diagnostik der Hand. English. Diagnostic imaging of the hand / [edited by] Ulrich Lanz, Rainer Schmitt ; with contributions by Wolfgang Buchberger ... [et al. ; translator, Adele Barbara Herzberger ; illustrators, Piotr and Malgorzata Gusta]. p. ; cm. Authorized and revised translation of the German edition published and copyrighted 2004 by Georg Thieme Verlag, Stuttgart, Germany. Includes bibliographical references and index. ISBN 978-3-13-140581-4 (TPS : alk. paper) -- ISBN 978-1-58890-453-9 (TPN : alk. paper) 1. Hand--Radiography. I. Lanz, Ulrich, M.D. II. Schmitt, Rainer, 1954- III. Buchberger, Wolfgang. IV. Title. [DNLM: 1. Hand Injuries--diagnosis. 2. Bone Diseases--diagnosis. 3. Diagnostic Imaging--methods. 4. Joint Diseases--diagnosis. WE 830 B595 2007a] RC951.B5215 2007 617.5'75075--dc22 2007017382

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

This book is an authorized and revised translation of the German edition published and copyrighted 2004 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Bildgebende Diagnostik der Hand.

Translator: Adele Barbara Herzberger, MD, Munich, Germany Illustrator: Piotr and Malgorzata Gusta, Paris, France

© 2008 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA http://www.thieme.com

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Cover design: Thieme Publishing Group Typesetting by Fotosatz Sauter, Donzdorf, Germany Printed by Druckerei Grammlich, Pliezhausen, Germany ISBN 978-3-13-14058-4 (TPS, Rest of World) ISBN 978-1-58890-453-9 (TPN, The Americas) 1 2 3 4 5 6

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V

Preface The last decade has witnessed considerable changes in radiological diagnosis of the hand. First, the spectrum of radiological procedures was extended by the introduction of multidetector spiral CT with the acquisition of nearly isotropic voxels, contrast-enhanced MRI with phased-array coils that enable the soft tissues of the hand to be imaged in finest anatomical detail, and finally by ultrasound and skeletal scintigraphy. Second, the spectrum of therapeutic options significantly increased at about the same time, especially with the establishment of microsurgical procedures. Third, there was a significant increase in knowledge of the biomechanics and pathophysiology of the carpus. Meanwhile, this increase in knowledge has led to the need for information among the different specialties that are involved in the diagnosis and treatment of hand diseases. Furthermore, modern radiology does not only provide many possibilities in depicting the small parts of the hand, but also has simultaneously created some uncertainty regarding the correct indication, examining procedures, and image interpretation of the complex hand anatomy and pathology. We authors have found ourselves in the fortunate position of being able to reciprocally measure the findings of our imaging routine with the clinical reality tested directly in the operating room and in the long-term follow-up. On the other hand, many therapeutic decisions were decisively influenced by the results produced with the help of modern imaging techniques. The goal of our interdisciplinary team was to closely correlate radiological signs of hand diseases with the underlying pathoanatomy, the clinical presentation, and the therapeutic options. This approach seemed the only successful way to impart the enormous amount of knowledge concerning the entities of hand diseases in a unified manner. Our book is intended to help the clinicians

(hand surgeons, orthopedists, rheumatologists) to understand the many possible interpretations of modern imaging and also to provide radiologists with clinical information for the correct implementation and interpretation of resulting images. The book is composed of four main sections. The methods section (Chapters 1–9) introduces the different examining methods. The following section (Chapters 10–16) presents the anatomical and functional foundations of hand imaging, the variants and malformations included. In the main section (Chapters 17–48), all important disease entities of the hand are discussed in a nosologic manner. Following definition, pathogenesis, and clinical symptoms, the diagnostic imaging of each disease is systematically explained. The final section with differential diagnostic tables (Chapters 49–62) presents even rare entities according to their symptoms in key words and with cross references to figures of this book. The terminology used in this book corresponds to the standardized nomenclature in Terminology for Hand Surgery published 2001 by the International Federation of Societies for Surgery of the Hand (IFSSH). The production of this book was only possible with the help of many diligent co-workers. We would like to express our gratitude to the staff at Thieme, first and foremost to Susanne Huiss, Gabriele Kuhn, and Elisabeth Kurz for their continual patience and consideration throughout the project. We would also like to thank Dr. Herzberger and Ms. Garrison for their excellent translation of the German text into English. We shall have attained our personal goal if this book leads to an improvement in diagnostic imaging in the anatomically special field of the hand, thus the usually young patients suffering from hand diseases would be the “winners.” Rainer Schmitt and Ulrich Lanz

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VII

List of Contributors Wolfgang Buchberger, MD Professor of Radiology Medical Director University Hospital Innsbruck Innsbruck, Austria

Viktor Metz, MD Professor of Radiology Department of Radiology University Hospital Vienna Vienna, Austria

Georgios Christopoulos, MD Senior Consultant Department of Radiology Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Karl-Josef Prommersberger, MD Associate Professor of Orthopedics Department of Hand Surgery Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Franz Fellner, MD Associate Professor of Radiology Department of Radiology General Hospital Linz Linz, Austria

Nicole Reutter, MD Radiologic Consultant Medical Treatment Center Theresientor Straubing, Germany

Steffen Froehner, MD Senior Consultant Department of Radiology Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany

Herbert Rosenthal, MD Senior Consultant Department of Radiology Hanover Medical School Hanover, Germany

Peter Hahn, MD Associate Professor of Surgery Department of Hand Surgery Vulpius Clinic Bad Rappenau, Germany

Gerhard Schindler, MD Professor Emeritus Department of Radiology University Hospital Würzburg Würzburg, Germany

Thomas Helmberger, MD Professor of Radiology Department of Radiology and Nuclear Medicine Municipal Hospital Bogenhausen Munich, Germany Andreas Heuck, MD Professor of Radiology Radiology Center Munich-Pasing Munich, Germany Alfred Horwitz, MD Senior Consultant Department of Pediatric Radiology Municipal Hospital Krefeld Krefeld, Germany Hermann Krimmer, MD Associate Professor of Surgery Department of Hand Surgery Ravensburg Hospital Ravensburg, Germany

Gerwin Lingg, MD Head Department of Radiology Rheuma-Heilbad AG Bad Kreuznach, Germany

Joerg van Schoonhoven, MD Associate Professor of Orthopedics Department of Hand Surgery Hospital for Cardiovascular Diseases Bad Neustadt an der Saale, Germany Sieglinde Spindler-Thiele, MD Senior Consultant Department of Radiology and Nuclear Medicine Klinikum Sozialstiftung Bamberg Bamberg, Germany Joerg Spitz, MD Associate Professor of Nuclear Medicine Society for Medical Information and Prevention Schlangenbad, Germany Axel Staebler, MD Associate Professor of Radiology Department of Radiology Orthopedic Hospital Harlaching Munich, Germany

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IX

Table of Contents Imaging Techniques of the Hand 1

........

1

Projection Radiography: General Information and Positioning Techniques . . . . . . . . . . . . . . . . . R. Schmitt

2

The Midcarpal Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Distal Radioulnar Joint . . . . . . . . . . . . . . . . . . . . . Indications for Diagnostic Arthroscopy . . . . . . . . . . . . Indications for Therapeutic Arthroscopy . . . . . . . . . . . Contraindications and Complications. . . . . . . . . . . . . .

33 33 33 34 34

5

Arteriography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T. Helmberger, R. Schmitt

36 36 36 37 39 40 40 40 41 43

General Techniques for Radiologic Diagnosis of Hand Abnormalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . Radiographs of the Entire Hand . . . . . . . . . . . . . . . . . Radiographs of the Wrist . . . . . . . . . . . . . . . . . . . . . . . The Scaphoid Quartet Series . . . . . . . . . . . . . . . . . . . . Radiographs of the Other Carpal Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiological Stress Views of the Carpus and Thumb. . . . . . . . . . . . . . . . . . . . . . . Radiographs of the Metacarpal Region. . . . . . . . . . . Radiographs of the Thumb and Finger . . . . . . . . . . .

8 10 10

Anatomy and Variants of Hand Arteries . . . . . . . . . . . Forearm Arteries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arteries in the Palm . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arteries of the Finger . . . . . . . . . . . . . . . . . . . . . . . . . . Arteries of the Dorsum of the Hand . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Catheter Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . MR Angiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specific Differential Indications . . . . . . . . . . . . . . . . .

2

Special Radiographic Procedures . . . . . . . . . . . . R. Schmitt, S. Froehner

13

6

Skeletal Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . J. Spitz

45

Digital Radiographic Procedures . . . . . . . . . . . . . . . . . . Digital Luminescence Radiography (DLR) . . . . . . . . Direct Radiography with Flat Detectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Image-intensifying Radiography . . . . . . . . . . . . . . . . Radiography with Mammography Films . . . . . . . . . . . Techniques in Magnification Radiography . . . . . . . . . Magnification Radiography with Mammography Equipment . . . . . . . . . . . . . . . . . . . . . Magnification Radiography with the DIMA Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low-kilovoltage Technique . . . . . . . . . . . . . . . . . . . . . . . Conventional Tomography. . . . . . . . . . . . . . . . . . . . . . . . Cineradiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 13

Physical-Technical Foundations . . . . . . . . . . . . . . . . . . . Biological Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . Factors Influencing Scintigraphic Images . . . . . . . . . . Indications for Skeletal Scintigraphy . . . . . . . . . . . . . . Scintigraphic Peculiarities among Children . . . . . . . .

45 46 48 49 52

7

Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . W. Buchberger, R. Schmitt, G. Christopoulos

54 54 55

17 17 20 20

3

Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V. Metz, R. Schmitt, G. Christopoulos

23

Physical Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-scan Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . Doppler Ultrasonography and Color-coded Doppler Ultrasonography. . . . . . . . . . . . . . . . . . . . . . . . . Special Prerequisites for Ultrasonographic Examination of the Small Parts of the Hand . . . . . . . . Normal Ultrasonographic Findings . . . . . . . . . . . . . . . . Examination Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anatomical Considerations . . . . . . . . . . . . . . . . . . . . . . . Arthrography of the Large Joint Spaces . . . . . . . . . . . . Arthrography of the Small Joint Spaces . . . . . . . . . . . . Arthrography of the Pisotriquetral Joint . . . . . . . . . Arthrography of the Saddle Joint of the Thumb. . . Arthrography of the Finger Joints . . . . . . . . . . . . . . . . . Indications and Assessment . . . . . . . . . . . . . . . . . . . . . .

23 24 27 27 27 28 28

4

Arthroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H. Krimmer, P. Hahn

30

Necessary Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthroscopic Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normal Arthroscopic Findings . . . . . . . . . . . . . . . . . . . . The Radiocarpal Joint . . . . . . . . . . . . . . . . . . . . . . . . . .

30 31 32 32

2 3 3 3 6 7

14 15 15 16 16

8

56 57 58 58 61

Computed Tomography. . . . . . . . . . . . . . . . . . . . . . R. Schmitt, S. Froehner

63

General Principle of CT . . . . . . . . . . . . . . . . . . . . . . . . . . . Spiral CT Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imaging Parameters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Artifacts in CT Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . Examination Techniques for CT of the Hand. . . . . . . . Image Postprocessing from CT Volume Datasets . . . . Normal Anatomy with Evaluation of the Slice Planes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CT Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteoabsorptiometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

63 63 64 65 65 67

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Magnetic Resonance Imaging . . . . . . . . . . . . . . . . F. Fellner, R. Schmitt

75

MR Imaging Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pulse Sequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spin-Echo Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . Fast Spin-Echo Technique . . . . . . . . . . . . . . . . . . . . . . Inversion Recovery Technique . . . . . . . . . . . . . . . . . . Gradient-Echo Technique. . . . . . . . . . . . . . . . . . . . . . . GRE Sequences with Dephasing of the Transverse Magnetization . . . . . . . . . . . . . . . . . . . . . . GRE Sequences with Rephasing of the Transverse Magnetization . . . . . . . . . . . . . . . . . . . . . . GRE Sequences of Special Design. . . . . . . . . . . . . . . . . . Three-dimensional Technique (3D Technique) . . . Fat-Saturation Techniques . . . . . . . . . . . . . . . . . . . . . . . . Parallel Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contrast Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contrast Medium Effects . . . . . . . . . . . . . . . . . . . . . . . Contrast Medium Administration for Standard Investigations . . . . . . . . . . . . . . . . . . . . . . . . Contrast-Enhanced MR Angiography . . . . . . . . . . . . MR Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nephrogenic Systemic Fibrosis (NSF) . . . . . . . . . . . . Dynamic MR Imaging of the Carpus . . . . . . . . . . . . . . . Planning of the Examination Volume . . . . . . . . . . . . . . Recommendations for MR Imaging Sequences for Examining the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . Sequence Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic MR Imaging Protocol . . . . . . . . . . . . . . . . . . . . . MR Imaging Protocol in Carpal Trauma . . . . . . . . . . MR Imaging Protocol in Scaphoid Trauma . . . . . . . MR Imaging Protocol in Nonunion of the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MR Imaging Protocol in Lesions of the Ligaments and the Tri-angular Fibrocartilage Complex . . . . . . MR Imaging Protocol in Carpal Osteonecrosis (Lunate Osteonecrosis) . . . . . . . . . . . . . . . . . . . . . . . . MR Imaging Protocol in Arthritic Joint Diseases . . MR Imaging Protocol for Identification of Ganglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MR Imaging Protocol for Diagnosis of Soft-tissue Tumors and Bone Tumors . . . . . . . . . . . . . . . . . . . . . . Normal MR Anatomy of the Hand . . . . . . . . . . . . . . . . .

75 75 76 76 77 77

9

Anatomic and Functional Prerequisites for Diagnostic Imaging of the Hand . . . . . 10 Carpal Ligaments. . . . . . . . . . . . . . . . . . . . . . . . . . . . R. Schmitt

Ligaments of the “Distal V” . . . . . . . . . . . . . . . . . . . . . . . Ligaments of the “Dorsal V” . . . . . . . . . . . . . . . . . . . . Carpal Collateral Ligaments. . . . . . . . . . . . . . . . . . . . . Pathoanatomical Principles . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

102 103 103 104 104 104 112 112

78

11 Triangular Fibrocartilage Complex . . . . . . . . . . . 114 R. Schmitt

78 78 79 80 81 81 81

Fundamental Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathoanatomic Principles . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiographic Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . .

82 82 82 83 83 83 84 84 85 85 85 85 86 87 87 87 88 88

97 98

Fundamental Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Interosseous Ligaments . . . . . . . . . . . . . . . . . . . . . . . . 98 Palmar V-shaped Ligaments . . . . . . . . . . . . . . . . . . . . 101 Ligaments of the “Proximal V” . . . . . . . . . . . . . . . . . . . . 101

114 116 117 117 121 121 121 121

12 Carpal Morphometry and Function . . . . . . . . . . 123 R. Schmitt, K. J. Prommersberger Morphometry and Function of the Distal Forearm . . Joint Angle of the Distal Radius Segment . . . . . . . . Relative Lengths of the Radius and the Ulna . . . . . Radioulnar Translation . . . . . . . . . . . . . . . . . . . . . . . . . Rotation of the Forearm (Pronosupination) . . . . . . Morphometry and Function of the Carpus . . . . . . . . . Radiographic Carpal Arches. . . . . . . . . . . . . . . . . . . . . Carpal Angles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carpal Height. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ulnar Deviation of the Carpus . . . . . . . . . . . . . . . . . . Carpal Movement Planes and Axes . . . . . . . . . . . . . . Flexion and Extension. . . . . . . . . . . . . . . . . . . . . . . . . . Radial and Ulnar Inclination . . . . . . . . . . . . . . . . . . . . Concepts of Carpal Stability and Instability . . . . . .

123 123 124 124 125 125 125 125 126 127 127 127 128 130

13 Postsurgical Radiography. . . . . . . . . . . . . . . . . . . . 133 H. Krimmer, P. Hahn, R. Schmitt Partial Arthrodesis of the Wrist . . . . . . . . . . . . . . . . . . . Surgery of the Distal Ulna . . . . . . . . . . . . . . . . . . . . . . . . Shortening of the Radius and Ulna . . . . . . . . . . . . . . . . Surgery for Fractures and Nonunion of the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgery for Radius Fractures and Corrective Osteotomy of the Radius . . . . . . . . . . . . . . . . . . . . . . . . . Surgery for Carpal Instability, Dislocations, and Dislocation Fractures. . . . . . . . . . . . . . . . . . . . . . . . . Surgical Salvage Procedures on the Phalangeal Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgery of Phalangeal Fractures . . . . . . . . . . . . . . . . . . . Arthrodesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Soft-Tissue and Callus Distractions . . . . . . . . . . . . . . . . Surgery of Traumatic Amputations . . . . . . . . . . . . . . . .

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Growth, Normal Variants, and Malformations of the Hand . . . . . . . . . . . . . . .

145

14 The Growing Skeleton of the Hand . . . . . . . . . . . 146 A. Horwitz, G. Schindler Normal Development of the Skeleton of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disturbances in Skeletal Maturation. . . . . . . . . . . . . . . Legal and Forensic Considerations. . . . . . . . . . . . . . . . . Evaluation Methods in Diagnostic Imaging. . . . . . . . . Age-dependent Factors. . . . . . . . . . . . . . . . . . . . . . . . . Determination of Skeletal Age . . . . . . . . . . . . . . . . . . Determination of the Prospective Mature Body Height . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

146 146 148 148 148 148 150

15 Normal Variants of the Skeleton and the Soft Tissues of the Hand . . . . . . . . . . . . . . . . . 151 R. Schmitt, G. Schindler Normal Variants of the Skeleton of the Hand . . . . . . . Sesamoid Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coalescence of the Carpals . . . . . . . . . . . . . . . . . . . . . Divided Carpals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accessory Carpal Bones . . . . . . . . . . . . . . . . . . . . . . . . Notches and Depressions in Carpal Bones. . . . . . . . Variants in the Shape of the Lunate . . . . . . . . . . . . . Normal Variants of the Soft Tissues of the Hand . . . . Variants of the Extrinsic and Intrinsic Muscles . . . Duplication of Tendons and Manifold Tendons . . . High Division of the Median Nerve . . . . . . . . . . . . . . Persisting Median Artery . . . . . . . . . . . . . . . . . . . . . . .

151 151 151 153 153 154 154 155 155 155 155 155

16 Malformations and Deformities . . . . . . . . . . . . . 158 J. van Schoonhoven, R. Schmitt, A. Horwitz, H. Rosenthal, U. Lanz Failure of Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transverse Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Longitudinal Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . Failure of Differentiation (Separation) of Parts . . . . . Symphalangy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Camptodactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinodactyly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pollex Flexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthrogryposis Multiplex Congenita. . . . . . . . . . . . . Syndactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Duplication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radial (Preaxial) Polydactyly. . . . . . . . . . . . . . . . . . . . Ulnar (Postaxial) Polydactyly . . . . . . . . . . . . . . . . . . . Central Polydactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mirror Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overgrowth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Undergrowth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypoplasia and Aplasia of the Thumb . . . . . . . . . . . Brachydactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constriction-Ring Syndrome. . . . . . . . . . . . . . . . . . . . . .

160 160 160 162 162 162 163 164 164 165 168 168 169 169 169 170 171 171 171 172

Malformation Syndromes (Generalized Abnormalities) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skeletal Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skeletal Dysostosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skeletal Dysplasia (Osteochondrodysplasia) . . . . . Congenital Sclerosing and Hyperostotic Skeletal Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Metabolic Disorders of the Skeleton (Dysostosis Multiplex) . . . . . . . . . . . . . . . . . . . . . . . . .

Injuries of the Hand and Traumatic Sequelae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173 174 174 175 176 177

181

17 Trauma of the Distal Forearm. . . . . . . . . . . . . . . . 182 K. J. Prommersberger, S. Froehner, J. van Schoonhoven, R. Schmitt Acute Fractures and Dislocation Fractures of the Distal Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Malunion of Distal Radius Fractures . . . . . . . . . . . . . . . Nonunion after Distal Radius Fractures . . . . . . . . . . . . Dislocations in the Distal Radioulnar Joint . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

182 195 196 197 198

18 Lesions in the Ulnocarpal Compartment . . . . . 200 R. Schmitt, G. Christopoulos, H. Krimmer Lesions of the Triangular Fibrocartilage Complex . . . Ulnocarpal Impaction Syndrome (Ulnolunate, Ulnolunotriquetral) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

200 213 215 215

19 Fractures of the Scaphoid. . . . . . . . . . . . . . . . . . . . 217 R. Schmitt, H. Krimmer, J. Spitz Pathophysiology and Clinical Symptoms . . . . . . . . . . . Special Considerations in Childhood. . . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

217 219 220 228 228

20 Scaphoid Nonunion . . . . . . . . . . . . . . . . . . . . . . . . . 230 R. Schmitt, H. Krimmer Pathogenesis and Clinical Symptoms . . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options and Posttherapeutic Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

230 232 240 241 242

21 Fractures of the Carpus Excluding the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 G. Christopoulos, R. Schmitt, J. Spitz Fractures of the Triquetrum . . . . . . . . . . . . . . . . . . . . . . 246 Fractures of the Pisiform . . . . . . . . . . . . . . . . . . . . . . . . . 248

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Fractures of the Lunate . . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Capitate . . . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Hamate . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Trapezium . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Trapezoid . . . . . . . . . . . . . . . . . . . . . . . . Combined Carpal Fractures . . . . . . . . . . . . . . . . . . . . . . . Special Features of Carpal Fractures in Children . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

249 251 252 254 255 256 257 257 257

22 Carpal Dislocations and Fracture-Dislocations . . . . . . . . . . . . . . . . . . . . . . . 259 A. Staebler, R. Schmitt, H. Krimmer Perilunate and Lunate Dislocations . . . . . . . . . . . . . . . . Perilunate Fracture-Dislocations . . . . . . . . . . . . . . . . . . Transscaphoid Perilunate Fracture-Dislocation (de Quervain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perilunate Dislocations with Other Accompanying Fractures . . . . . . . . . . . . . . . . . . . . . . . Scaphoid-Capitate Fracture Syndrome (Fenton) . . . . Axial Dislocations and Fracture-Dislocations . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261 264 264 264 266 267 268 268

23 Carpal Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 R. Schmitt, A. Staebler, H. Krimmer Dissociative Carpal Instability (CID) . . . . . . . . . . . . . . . Scapholunate Dissociation (SLD) . . . . . . . . . . . . . . . . Lunotriquetral Dissociation (LTD) . . . . . . . . . . . . . . . Nondissociative Carpal Instability (CIND) . . . . . . . . . . Radiocarpal Instability . . . . . . . . . . . . . . . . . . . . . . . . . Midcarpal Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . Capitolunate Instability . . . . . . . . . . . . . . . . . . . . . . . . Ulnar Translocation of the Carpus . . . . . . . . . . . . . . . Carpal Translocations to the Radial, Palmar, or Dorsal Aspect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . .

274 274 281 286 286 286 288 288 290 291

24 Carpometacarpal Dislocations and Fracture-Dislocations . . . . . . . . . . . . . . . . . . . . . . . 293 R. Schmitt, P. Hahn Dorsal Carpometacarpal Dislocations. . . . . . . . . . . . . . Palmar Carpometacarpal Dislocations . . . . . . . . . . . . . Dorsal Carpometacarpal Fracture-Dislocations . . . . . Palmar Carpometacarpal Fracture-Dislocations . . . . Differential Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

294 294 294 296 296 297

25 Metacarpal Fractures . . . . . . . . . . . . . . . . . . . . . . . . 298 H. Krimmer, G. Schindler Fractures Close to the Base of Metacarpal I. . . . . . . . . Fractures of the Bases of the Metacarpals II–V. . . . . . Fractures of the Metacarpal Shafts . . . . . . . . . . . . . . . . Subcapital Metacarpal Fractures . . . . . . . . . . . . . . . . . .

299 300 301 301

Fractures of the Metacarpal Heads . . . . . . . . . . . . . . . . 302 Differential Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 26 Fractures and Dislocations of the Fingers . . . . 304 P. Hahn, R. Schmitt, N. Reutter Extra-articular Fractures . . . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Tuberosity of the Distal Phalanx . Fractures of the Finger Shafts . . . . . . . . . . . . . . . . . . . Intra-articular Finger Fractures . . . . . . . . . . . . . . . . . . . Avulsion Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dorsal Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the Extensor Tendon) . . . . . . . . Palmar Fracture of the Base of the Distal Phalanx (Avulsion Lesion of the Deep Flexor Tendon) . . . . . Dorsal Fracture of the Base of the Middle Phalanx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Palmar Fractures of the Bases of the Middle and Distal Phalanges . . . . . . . . . . . . . . . . . . . . Pediatric Fractures of the Fingers. . . . . . . . . . . . . . . . . . Finger Dislocations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture-Dislocations of the Fingers . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of the Hand Caused by Local or Systemic Degeneration . . . . . . . . . . . . . . . .

306 306 306 306 308 308 308 309 309 310 310 312 312 312

315

27 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 A. Staebler, R. Schmitt, H. Krimmer Osteoarthritis of the Finger Joints . . . . . . . . . . . . . . . . . Osteoarthritis of the Carpal Joints . . . . . . . . . . . . . . . . . Osteoarthritis of the Carpometacarpal Joint I (“Rhizarthrosis”). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteoarthritis of the Scaphotrapeziotrapezoid Joints (STT Osteoarthritis) . . . . . . . . . . . . . . . . . . . . . . Osteoarthritis of the Pisotriquetral Joint . . . . . . . . . Osteoarthritis Associated with Carpal Collapse (SLAC Wrist and SNAC Wrist) . . . . . . . . . . . . . . . . . . . Osteoarthritis of the Distal Radioulnar Joint. . . . . . Special Forms of Osteoarthritis of the Hand . . . . . . . . Inflammatory (Erosive) Osteoarthritis . . . . . . . . . . . Combined Degenerative-Rheumatoid Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chondrocalcinosis (Pseudogout, CPPD Deposition Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

318 319 319 320 320 321 324 325 325 325 326 326 327 327

28 Enthesopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 N. Reutter, S. Spindler-Thiele Predominantly Fibro-ostotic Changes. . . . . . . . . . . . . . 330 Degenerative Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 330

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Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carpal Humps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endocrine Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypoparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . Metabolic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chondrocalcinosis, Peritendinitis Calcarea, Alcaptonuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Predominantly Fibro-ostitic Changes . . . . . . . . . . . . . . Inflammatory Diseases . . . . . . . . . . . . . . . . . . . . . . . . . Resorptive Fibro-ostitis. . . . . . . . . . . . . . . . . . . . . . . . . . . Productive Fibro-ostitis . . . . . . . . . . . . . . . . . . . . . . . . . . Combined Forms of Fibro-ostitic Lesions . . . . . . . . Rheumatoid and Seronegative Arthritides . . . . . . . Bacterial Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rare Affections of the Fibro-osseous Junction . . . . Differential Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

330 330 330 330 331 331 331 331 331 331 332 332 332 332 332 332 332 332 332 333

29 Soft-Tissue Lesions Caused by Overuse and Sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 A. Heuck, R. Schmitt, P. Hahn Tendinosis and Tenosynovitis . . . . . . . . . . . . . . . . . . . . . Tendinosis and Tenosynovitis of the Extensor Tendons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tendinosis and Tenosynovitis of the Flexor Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tendon Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Injuries of the Anular Pulleys . . . . . . . . . . . . . . . . . . . . . Gamekeeper’s Thumb . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lesions of the Second to Fifth Metacarpophalangeal Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bursitis of the Ulnar (Prestyloid) Recess . . . . . . . . . . . Muscular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

336 336 338 341 342 344 346 347 348 349

30 Osteonecrosis of the Hand Skeleton. . . . . . . . . . 351 R. Schmitt, H. Krimmer Lunate Osteonecrosis (Kienböck Disease) . . . . . . . . . . Scaphoid Osteonecrosis (Preiser Disease) . . . . . . . . . . Osteonecrosis of the Capitate Head . . . . . . . . . . . . . . . Osteonecrosis of the Hook of the Hamate . . . . . . . . . . Osteonecrosis of All Metacarpals (Caffey Disease) . . Osteonecrosis of the Metacarpal Heads (Mauclaire Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteonecroses of the Phalangeal Bases (Thiemann Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

351 362 363 364 364 364 365

31 Osteopenic Diseases in the Hands . . . . . . . . . . . . 366 N. Reutter, A. Heuck, V. Metz Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 Rickets/Osteomalacia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Renal Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 32 Algodystrophy (Reflex Dystrophy, Complex Regional Pain Syndrome Type I) . . . . 377 N. Reutter, J. Spitz Pathogenesis and Clinical Symptoms . . . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

377 379 381 382

Diseases of the Hand Related to Systemic Metabolic Diseases . . . . . . . . . . . . .

383

33 Osteopathies Caused by Hormones, Vitamins, Medications, or Toxins . . . . . . . . . . . . 384 A. Heuck, H. Rosenthal Endocrine Osteopathies . . . . . . . . . . . . . . . . . . . . . . . . . . Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypopituitarism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adrenogenital syndrome (AGS) . . . . . . . . . . . . . . . . . Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . Hypoparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . Pseudohypoparathyroidism and Pseudopseudohypoparathyroidism . . . . . . . . . . . . . . . . . . . . Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteopathies Caused by Hypovitaminosis or Hypervitaminosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vitamin D-deficiency Rickets . . . . . . . . . . . . . . . . . . . Vitamin D-resistant Rickets. . . . . . . . . . . . . . . . . . . . . Hypervitaminosis D. . . . . . . . . . . . . . . . . . . . . . . . . . . . Vitamin C Deficiency (Scurvy, Möller–Barlow Disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drug-induced and Toxic Osteopathies . . . . . . . . . . . . . Corticoid Osteopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . Prostaglandin Osteopathy . . . . . . . . . . . . . . . . . . . . . . Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aluminum Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . Lead Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

384 384 384 385 386 386 386 386 387 388 388 388 388 389 389 389 389 389 390 390 391

34 Crystal-induced Osteoarthropathies and Related Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392 T. Helmberger, A. Staebler, R. Schmitt Gouty Arthritis/Hyperuricemia . . . . . . . . . . . . . . . . . . . Calcium Pyrophosphate Dihydrate (CPPD) Deposition Disease (Pyrophosphate Arthropathy) . . Chondrocalcinosis of the Ligaments and the Triangular Fibrocartilage Complex (TFCC). . . . . . . . Destructive Osteoarthropathy of the Wrist. . . . . . . Tumorous Chondrocalcinosis . . . . . . . . . . . . . . . . . . .

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Further Manifestations of CPPD Deposition Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hydroxyapatite (HA) Deposition Disease (“Acute Calcium Deposition”) . . . . . . . . . . . . . . . . . . . . . Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wilson Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alkaptonuria (Ochronosis). . . . . . . . . . . . . . . . . . . . . . . . Oxalosis (Hyperoxaluria) . . . . . . . . . . . . . . . . . . . . . . . . .

397 398 400 401 401 402

35 Miscellaneous Osteoarthropathies . . . . . . . . . . . 404 S. Spindler-Thiele, R. Schmitt, A. Staebler

Familial Mediterranean Fever . . . . . . . . . . . . . . . . . . . 440 Stevens–Johnson Syndrome . . . . . . . . . . . . . . . . . . . . 441 38 Rheumatic Fever (Poststreptococcal Reactive Arthritis). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 S. Spindler-Thiele, G. Lingg Pathoanatomy and Clinical Symptoms. . . . . . . . . . . . . Radiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

442 442 443 443

Sarcoidosis (Boeck Disease). . . . . . . . . . . . . . . . . . . . . . . Neurogenic Osteoarthropathy and Charcot Osteoarthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemophilic Osteoarthropathy (“Bleeders’ Joints”) . . Amyloid Osteoarthropathy . . . . . . . . . . . . . . . . . . . . . . . Hereditary Hemoglobinopathies . . . . . . . . . . . . . . . . . . Multicentric Reticulohistiocytosis (Lipoid Arthrodermatitis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertrophic Osteoarthropathy. . . . . . . . . . . . . . . . . . . Radiation-induced Osteoarthropathy . . . . . . . . . . . . . . Foreign-body Synovitis and Arthritis . . . . . . . . . . . . . . Synovial Chondromatosis. . . . . . . . . . . . . . . . . . . . . . . . .

404

39 Collagenoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444 S. Spindler-Thiele, R. Schmitt

406 407 408 409

Systemic Lupus Erythematosus (SLE) . . . . . . . . . . . . . . Scleroderma, Progressive Systemic Sclerosis (PSS) . . Polymyositis and Dermatomyositis . . . . . . . . . . . . . . . . Panarteritis Nodosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wegener Granulomatosis. . . . . . . . . . . . . . . . . . . . . . . . . Sjögren Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inflammatory Diseases of the Hand . . . . .

417

410 411 412 413 414

36 Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . 418 G. Lingg, R. Schmitt Special Forms of Rheumatoid Arthritis . . . . . . . . . . . . Adult Still Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . Felty Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sjögren Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caplan Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile or Special Forms of Rheumatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiographic Classification of Stages of Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

420 420 420 420 420 420 428 429 429

37 Seronegative Spondylarthropathies . . . . . . . . . . 431 S. Spindler-Thiele, A. Staebler, G. Lingg Psoriatic Arthritis (Psoriatic Osteoarthropathy) . . . . Reiter Syndrome (Reiter disease). . . . . . . . . . . . . . . . . . Reactive Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthritis with Ankylosing Spondylitis (Marie–Strümpell Disease, Bechterew Syndrome) . . Enteropathic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteoarthropathies Associated with Dermatoses . . . Rare Seronegative Arthritides . . . . . . . . . . . . . . . . . . . . . Antibody-deficiency Syndrome . . . . . . . . . . . . . . . . . Hashimoto Autoimmune Thyroiditis . . . . . . . . . . . . Behçet Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

434 436 437 438 439 440 440 440 440 440

444 446 448 449 449 450

40 Infectious Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . 451 S. Spindler-Thiele, R. Schmitt Acute Bacterial Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . Tuberculosis of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gonococcal Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leprosy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lyme Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bilharziosis Arthropathy . . . . . . . . . . . . . . . . . . . . . . . . . Viral Arthritides (Hepatitis B, Rubella, Mumps, Variola, Parvo-B19, Vaccinia). . . . . . . . . . . . . . . . . . . . . . Fungal Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inflammatory Diseases of the Bones and Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . .

454 454 455 455 455 456 456 456 456

459

41 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460 H. Rosenthal, R. Schmitt, J. Spitz Hematogenous Osteomyelitis . . . . . . . . . . . . . . . . . . . . . Tuberculous Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . Secondary Osteomyelitides . . . . . . . . . . . . . . . . . . . . . . . Phalangeal Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . Posttraumatic Osteomyelitis . . . . . . . . . . . . . . . . . . . . Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Forms of Osteomyelitis. . . . . . . . . . . . . . . . . . . . Plasma-cell Osteomyelitis, Brodie Abscess, Garré Chronic Sclerosing Osteomyelitis. . . . . . . . . . Osteomyelitides Caused by Rare Organisms . . . . . . Chronic Recurrent Multifocal Osteomyelitis. . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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42 Infections of the Soft Tissues . . . . . . . . . . . . . . . . 468 P. Hahn, R. Schmitt Infections of the Fingertips and Paronychia . . . . . . . . Pyogenic Flexor Tenosynovitis . . . . . . . . . . . . . . . . . . . . Deep Space Infections in the Palm. . . . . . . . . . . . . . . . . Tuberculosis of the Tendon Sheath . . . . . . . . . . . . . . . . Acute Calcium Deposition . . . . . . . . . . . . . . . . . . . . . . . . Gangrenous Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

469 470 471 473 474 474 474 474

Tumorous and Tumorlike Diseases of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

477

43 Cystic Bone Lesions . . . . . . . . . . . . . . . . . . . . . . . . . 478 N. Reutter, F. Fellner Bone Cysts with No Pathological Relevance . . . . . . . . Vasa Nutricia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Posttraumatic Hemorrhagic Cysts . . . . . . . . . . . . . . . Necrobiotic Pseudocysts, Idiopathic Carpal Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Avascular Osteonecroses of the Carpus . . . . . . . . . . . . Enthesopathic and Arthritic Diseases . . . . . . . . . . . . . . Signal Cysts and Arthritic Erosions . . . . . . . . . . . . . . Bone Cysts Induced by Infection . . . . . . . . . . . . . . . . . . Bone Cysts in Systemic Diseases . . . . . . . . . . . . . . . . . . Metabolic Diseases That are Associated with Deposits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chondrocalcinosis (CPPD Deposition) . . . . . . . . . . . . . Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Xanthomatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Cysts in Other Systemic Diseases . . . . . . . . . . “Brown Tumors” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sarcoidosis (Osteitis Multiplex Cystices Jüngling) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gaucher Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibrous Dysplasia (Jaffé–Lichtenstein Disease) . . . Neurofibromatosis type I (Recklinghausen Disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tuberous Sclerosis (Pringle–Bourneville Disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cystic Bone Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

478 478 478 479 479 479 481 482 482 482 482 482 482 482 482 483 483 483 483 483 484 484 485 485 485

44 Bone Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486 H. Rosenthal, R. Schmitt, A. Staebler Bone Tumors of Chondrogenous Origin . . . . . . . . . . . . Enchondroma (Chondroma). . . . . . . . . . . . . . . . . . . . . Osteochondroma (Cartilaginous Exostosis) . . . . . . Chondroblastoma, Chondromyxoid Fibroma . . . . .

487 487 489 490

Chondrosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Tumors Originating from Osseous Tissue . . . . . Osteoid Osteoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteoblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Tumors Originating from Connective Tissue . . Nonossifying Fibroma, Desmoplastic Fibroma . . . . Giant-cell Tumor (Osteoclastoma) . . . . . . . . . . . . . . Malignant Fibrous Histiocytoma (MFH), Fibrosarcoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Tumors Originating from the Endothelium . . . Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemangioendothelioma, Angiosarcoma . . . . . . . . . Bone Tumors Originating from the Bone Marrow . . . Ewing Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiple Myeloma (Plasmacytoma), Malignant Lymphoma, Hodgkin Disease, and Leukemia . . . . . Tumorlike Bone Lesions of the Hand . . . . . . . . . . . . . . Enostoma, Bone Island . . . . . . . . . . . . . . . . . . . . . . . . . Aneurysmal Bone Cyst . . . . . . . . . . . . . . . . . . . . . . . . . Solitary Bone Cyst (Juvenile Bone Cyst) . . . . . . . . . . Reparative Giant-cell Granuloma. . . . . . . . . . . . . . . . Miscellaneous Joint Diseases and Intraosseous Ganglion Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intraosseous Epidermal Cyst. . . . . . . . . . . . . . . . . . . . “Brown Tumor” in Hyperparathyroidism . . . . . . . . Other Bone Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Soft-tissue Tumors with Osseous Infiltration . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

490 491 491 493 493 493 493 493 494 494 494 494 496 496 496 497 497 497 498 498 498 499 499 499 499 499 500

45 Soft-tissue Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . 502 R. Schmitt Tumors of Cutaneous Origin . . . . . . . . . . . . . . . . . . . . . . Epidermal Inclusion Cyst . . . . . . . . . . . . . . . . . . . . . . . Cutaneous Carcinomas . . . . . . . . . . . . . . . . . . . . . . . . . Tumors Originating from Connective Tissue. . . . . . . . Ganglion Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibroma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leiomyoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Giant-cell Tumor of the Tendon Sheath (“Xanthoma”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aggressive Fibromatosis (Desmoid Tumor) . . . . . . Soft-tissue Sarcomas . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumors Originating from Blood Vessels and Lymphatic Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemangiomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Malignant Vascular Tumors. . . . . . . . . . . . . . . . . . . . . Glomus Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lymphangiomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumors Originating from Neural Tissue. . . . . . . . . . . . Neurinoma (Schwannoma) and Neurofibroma . . . Intraneural Fibrolipoma . . . . . . . . . . . . . . . . . . . . . . . . Malignant Neurinoma (Neurofibrosarcoma) . . . . .

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504 504 505 505 505 507 508 508 509 510 511 513 513 515 515 515 517 517 518 518

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XVI

Table of Contents

Posttraumatic Neuroma . . . . . . . . . . . . . . . . . . . . . . . . 518 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520 Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520

Neuropathies and Vasculopathies of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

523

46 Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . 524 W. Buchberger, R. Schmitt Preliminary Remarks on Anatomy. . . . . . . . . . . . . . . . . Pathophysiology and Clinical Symptoms . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postsurgical Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

524 525 526 530 530

47 Ulnar Tunnel Syndrome (Guyon’s Canal Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532 R. Schmitt, P. Hahn Preliminary Remarks on Anatomy. . . . . . . . . . . . . . . . . Pathoanatomy and Clinical Symptoms. . . . . . . . . . . . . Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Differential Diagnostic Tables: Diseases of the Hand . . . . . . . . . . . . . . . . . . . . . .

549

49 Congenital and Acquired Alterations in Form and Structure of the Epiphyses . . . . . . 550 A. Horwitz 50 Congenital and Acquired Alterations in Form and Structure of the Metaphyses . . . . 551 A. Horwitz 51 Malformation Syndromes . . . . . . . . . . . . . . . . . . . 552 G. Schindler, R. Schmitt 52 Dysplasias (Osteochondrodysplasias) . . . . . . . . 556 G. Schindler, A. Horwitz 53 Primary Metabolic Disorders of the Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560 G. Schindler, A. Horwitz

532 533 533 535

54 Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562 S. Spindler-Thiele

48 Vascular Diseases of the Hand and Fingers . . . 536 H. Rosenthal, R. Schmitt

55 Acro-osteolyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567 R. Schmitt, S. Spindler-Thiele

Peripheral Vascular Disease (Atherosclerosis) . . . . . . Peripheral Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endangiitis Obliterans (Winiwarter–Buerger Disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Raynaud Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collagenoses and Rheumatoid Arthritis. . . . . . . . . . . . Scleroderma (Progressive Systemic Sclerosis) . . . . Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . Panarteritis Nodosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rare Vascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . Vascular Injuries and Postsurgical Angiographic Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Vibration Injury . . . . . . . . . . . . . . . . . . . . . . . Hypothenar (Ulnar) Hammer and Thenar Hammer Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiation-induced Arteriopathies . . . . . . . . . . . . . . . Vascular Injuries and False Aneurysms . . . . . . . . . . Postsurgical Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . Tumors of the Bones and Soft Tissues . . . . . . . . . . . . . Congenital Malformations . . . . . . . . . . . . . . . . . . . . . . . . Arteriovenous Malformations. . . . . . . . . . . . . . . . . . . . . Genuine Diffuse Phlebectasia . . . . . . . . . . . . . . . . . . . Klippel–Trénaunay Syndrome . . . . . . . . . . . . . . . . . . Weber Arteriovenous Malformation. . . . . . . . . . . . . Servelle–Martorell Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maffucci Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

536 537 538 539 540 540 540 540 541 541 541 541 542 543 543 544 544 544 545 545 545 545 546 546 547

56 Cystic Bone Inclusions . . . . . . . . . . . . . . . . . . . . . . . 571 N. Reutter 57 Polyostotic Bone Lesions . . . . . . . . . . . . . . . . . . . . 573 H. Rosenthal, R. Schmitt 58 Lesions of the Periosteum and Cortical Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576 N. Reutter 59 Hyperostoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580 N. Reutter

60 Osteopenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582 N. Reutter

61 Soft-tissue Calcifications . . . . . . . . . . . . . . . . . . . . 584 R. Schmitt, G. Christopoulos

62 Secondary Raynaud Phenomena . . . . . . . . . . . . . 588 H. Rosenthal

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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591

XVII

Abbreviations 2D 3D 67 Ga 99m Tc A/D ACE ACTH AGS AHS ANA APL ARA ASD a-Si ASIF ASPED AV AVM BMC Bq CCD CH CHL CIA CIC CID CIND CISS CLIP CMC CP CPPD CR CREST

CRP CRPS CT CU CW DD DEQCT DESS DGC DIC DICL

two-dimensional three-dimensional gallium-67 technitium-99m analog/digital angiotensin-converting enzyme adrenocorticotropic hormone adrenogenital syndrome acquired hyperostosis syndrome anti-nuclear antibodies abductor pollicis longus American Rheumatism Association atrial septum defect amorphous silicon Association for the Study of Internal Fixation angle-shaped phalangoepiphyseal dysplasia arteriovenous arteriovenous malformation bone mineral content (mg/ml) becquerel (SI unit of radionuclide activity; 1 Bq = 1 s–1) charge-coupled device capitohamate capitohamate ligament carpal instability axial carpal instability complex carpal instability dissociative carpal instability nondissociative constructive interference in the steady state capitolunate instability pattern carpometacarpal chronic polyarthritis calcium-pyrophosphate dihydrate collateral radial C = calcinosis (Thibièrge–Weissenbach syndrome), R = Raynaud’s phenomenon, E = esophageal dysfunction, S = sclerodactyly, T = telangiectasias C-reactive protein complex regional pain syndrome computed tomography collateral ulnar continuous-wave differential diagnosis dual-energy QCT dual echo steady state depth gain compensation dorsal intercarpal dorsal intercarpal ligament

DIMA DIP DISH DISI DLE DLR DNA DPA DRT DRTL DRUJ DSA DSI DXA EANM ECRB ECRL ECU ED EDM EIP EMG EMO ENG EPB EPI EPL ESR ETL FCR FCU FDP FDS FFD FFE FISP FLAIR FLASH FoV FPL fs FSE FSPGR Gd Gph Gr GRAPPA GRASS

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direct radiographic magnification distal interphalangeal diffuse idiopathic skeletal hyperostosis (Forestier disease) dorsal intercalated segment instability disseminated lupus erythematosus digital luminescence radiography deoxyribonucleic acid dual-photon absorptiometry dorsal radiotriquetral Dorsal radiotriquetral ligament distal radioulnar joint digital subtraction angiography digital spot imaging dual x-ray absorptiometry European Association of Nuclear Medicine extensor carpi radialis brevis extensor carpi radialis longus extensor carpi ulnaris extensor digitorum extensor digiti minimi extensor indicis proprius electromyography exophthalmus, myxedema, hypertrophic osteoarthropathy electroneurography extensor pollicis brevis echo-planar imaging extensor pollicis longus erythrocyte sedimentation rate echo train length flexor carpi radialis flexor carpi ulnaris flexor digitorum profundus flexor digitorum superficialis film–focus distance fast field echo fast imaging with steady precession fluid-attenuated inversion recovery fast low-angle shot field of view flexor pollicis longus fat-saturated fast-spin-echo fast spoiled gradient-echo recalled gadolinium phase-encoding gradient selection gradient generalized autocalibrating partially parallel acquisition gradient-recalled acquisition in a steady state

XVIII

Abbreviations

GRE Gs Gy HA HF HGH HIG HIV HLA HU Hz ICD INR IP IR IU JCA Lp LT LTD LTL mAs MBq MCI mCi MCR MCTD MCU MEDIC MFH mGy MIP MP MPR MPS HI MPVR MR MRA MRI MTF MZ NHL NSAID P1 P2 P3 PACS PAS PD PDA pDXA PHP

gradient-recalled-echo slice-select gradient Gray (SI unit for a specific absorbed dose of radiation; 10–2 Gy = 1 rad) hydroxyapatite high-frequency human growth hormone human immunoglobulins human immunodeficiency virus human leukocyte antigen Hounsfield unit hertz (unit of frequency = 1 cycle/second) intercarpale dorsale international normalized ratio interphalangeal inversion-recovery international unit juvenile chronic arthritis line pair lunotriquetral lunotriquetral dissociation Lunotriquetral ligament milliampere-second mega-becquerel midcarpal instabilities millicurie (1 Ci = 3.7 × 1010 disintegrations s–1 = 3.7 × 1010 Bq) midcarpal radial mixed connective-tissue disease midcarpal ulnar multiecho data image combination malignant fibrous histiocytoma milliGray maximal intensity projection metacarpophalangeal multiplanar reconstruction mucopolysaccharidosis Hurler type I multiplanar volume reconstruction magnetic resonance magnetic resonance angiography magnetic resonance imaging modulation transfer function longitudinal magnetization non-Hodgkin lymphoma nonsteroidal anti-inflammatory drug proximal phalanx middle phalanx distal phalanx picture archiving and communication system periodic acid-Schiff proton-density persisting ductus arteriosus peripheral dual x-ray absorptiometry pseudohypoparathyroidism

PIP PISI POEMS

PPHP pQCT PSIF PSS PTT PVD PVNS QCT QMR QUS RA RC RCL rem RF RL RLT RLTL ROI RS RSC RSCL RSL RSLL RSS RTD RTDL RUD RUP SAE SAPHO SC SCL SE SENSE SEQCT SL SLAC SLD SLE SLL SMASH SNAC SNU SNR

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proximal interphalangeal palmar-flexed intercalated segment instability syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) pseudo-pseudohyperparathyroidism peripheral quantitative CT reversed FISP sequence progressive systemic sclerosis partial thromboplastin time peripheral vascular disease pigmented villonodular synovitis quantitative CT quantitative MRI quantitative ultrasound examination rheumatoid arthritis radial collateral radial collateral ligament roentgen-equivalent-man (1 sievert [Sv] = 100 rem) rheumatoid factor radiolunate radiolunotriquetral radiolunotriquetral ligament region of interest radioscaphoid radioscaphocapitate radioscaphocapitate ligament radioscapholunate radioscapholunate ligament rotation subluxation of the scaphoid dorsal radiotriquetral dorsal radiotriquetral ligament radioulnare dorsale radioulnare palmare stimulated acoustic emission synovitis, acne, pustular hyperostosis, osteomyelitis scaphocapitate scaphocapitate ligament spin-echo sensitivity encoding single-energy QCT scapholunate scapholunate advanced collapse scapholunate dissociation systemic lupus erythematosus scapholunate ligament simultaneous acquisition of special harmonics scaphoid nonunion advanced collapse scaphoid nonunion signal-to-noise ratio

XIX SPA SPGR SPIO SPIR SSD STH STIR STT STTL Sv SXA T1 T1-w T2 T2* T2-w TBD TCS TCSL

single-photon absorptiometry spoiled gradient-echo recalled superparamagnetic iron oxides spectral presaturation inversion recovery shaded-surface display somatotropic hormone (somatotropin; growth hormone) short tau inversion recovery scaphotrapeziotrapezoid scaphotrapeziotrapezoid ligament Sievert (SI unit of deose equivalent; 1 Sv = 1 J kg–1) single x-ray absorptiometry longitudinal relaxation time T1-weighted transverse relaxation time transverse relaxation time in gradientecho MRI T2-weighted trabecular density triquetrocapitoscaphoideal triquetrocapitoscaphoid ligament (arcuate ligament)

TD TE TFC TFCC TFE TI TNF TOF TPS TR TSE turbo-FLASH UC UCL UL ULL US USPIO UT UTL UV VR VSD

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total density echo time triangular fibrocartilage triangular fibrocartilage complex turbo field-echo inversion time tumor necrosis factor time of flight three-phase skeletal scintigraphy repetition time turbo spin-echo turbo fast low-angle shot ulnar collateral ulnar collateral ligament ulnolunate ulnolunate ligament ultrasonography ultrasmall superparamagnetic iron oxides ulnotriquetral ulnotriquetral ligament ultraviolet volume rendering ventricle septal defect

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Imaging Techniques of the Hand 1

Projection Radiography: General Information and Positioning Techniques

2

Special Radiographic Procedures .

3

. . . .

2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

Arthrography

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

4

Arthroscopy .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

5

Arteriography

6

Skeletal Scintigraphy

7

Ultrasonography

8

Computed Tomography

9

Magnetic Resonance Imaging

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

54

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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63 75

2

1

Projection Radiography: General Information and Positioning Techniques R. Schmitt

Radiographs of the hand are acquired according to standardized techniques in which positioning and centering must be carried out with great precision to avoid malalignment in the three spatial planes. To prevent pronosupination, the dorsopalmar and lateral views must be exposed in their respective neutral positions. With the elbow flexed, the forearm should

be adducted for a lateral view, whereas for the dorsopalmar view the upper arm is placed in abduction at the shoulder level. Because of to the superpositioning of skeletal parts in projection radiography, several special positions and projections are used for the carpus. Injuries to the ligaments of the carpus and the thumb can be demonstrated indirectly in stress views.

General Techniques for Radiologic Diagnosis of Hand Abnormalities Examining Instruments

Recording Systems and Exposure Parameters

Radiographs of the hand are acquired either on the universally usable Bucky table or on a special work surface for imaging of the hand (the Lysholm table). In the overtable technique, the x-ray cassette is placed on the surface of the table, and the patient’s hand is positioned on top of the cassette. The film–focus distance (FFD) is 10 5 cm; the fine focus is individually set (focus size 0.6 mm or less). A scattered radiation grid is not used.

For projection radiography, cassettes sized 18 × 24 cm and 24 × 30 cm are used. Three different recording systems are available: U In film–screen radiography for diagnosis in adults, the cassettes have intensifying screens with a sensitivity value of 400 (dose required: 5 µGy). Depending on the size of the hand, a tube voltage between 45 and 55 kV and a current–time product between 3 and 6 mAs are selected for any exposure (without automatic exposure timer). According to the guidelines of the German Federal Medical Chamber, high-resolution film–screen systems can also be used for special clinical indications. U In digital luminescence radiography, storage screens based on phosphorus compounds serve as detectors. The exposure parameters are about the same as for film–screen radiography. A characteristic of the digital luminescence technique is the higher range on a linear gradiation curve, permitting corrections of the image brightness and contrast during postprocessing. For diagnostic imaging of the hand, so-called K2 systems with 2048 × 2048 pixels are recommended. U With flat-panel detectors, the x-ray pattern is recorded directly onto silicate- or selenium-based detectors so that an intermediate read-out procedure is no longer necessary (direct radiography). This procedure offers improved quantum efficiency with increased signal-to-noise ratio (SNR) at the same radiation dose: in practice this means that the same image quality can be achieved with a lower radiation dose. Direct radiography systems are now used with increasing frequency.

Auxiliary Materials U

U

U

U

U

U U

For radiation protection, a lead coat and apron, as well as lead gloves for stress views. A positioning block made of light wood or plastic with the dimensions 25 × 35 × 50 cm. For dorsopalmar projections, the patient’s hand and forearm are placed on this positioning block at shoulder level (Fig.1.2 a). A positioning splint with vertical sides for strictly lateral views. Wedged pads made of foam rubber (Bocollo) in various sizes and angles (30°, 45°, and 60°). Small sacks filled with rice meal, Velcro bands, and adhesive tape for stable positioning and fixation of the patient’s hand. Markers to indicate “R” and “L” on the x-ray film. Lead strips to cover the nonexposed segments of the cassette.

Radiation Protection Measures The patient wears a lead apron or a lead coat for radiation protection and sits beside the examining table; the patient’s legs are not under the table.

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Special Imaging Techniques

Peculiarities in Childhood U

U

U

Aside from the use of high-gain intensifying screens with a sensitivity value of 400, the guidelines of the German Federal Medical Chamber require additional filtering with 1 mm aluminum and 0.1 mm copper for pediatric radiographic imaging. According to radiation protection regulations in Germany, storage screens can be exposed at a lower radiation dose in children, although the result is poorer (decreased) SNR.

U

Special Examination Techniques The following situations and techniques require modifications to the standard diagnostic procedure. U If the patient is immobile as a result of polytrauma or when postsurgical follow-up radiographs are being taken, auxiliary equipment is necessary for correct positioning and setup, such as placing the cassette laterally on the patient’s hand.

For imaging with mammography films, film–screen combinations with a sensitivity value of 25 are used (dose requirement: 40 µGy). The same film–focus distance of 105 cm requires an 8-fold higher radiation dose than with standard diagnostic techniques. This technique therefore cannot be applied routinely but only when specially indicated, as in the diagnosis of the initial stages of arthritis. In magnification and low-kilovoltage techniques, the film–focus distance is generally 65 cm. When conducted with a mammography unit using film–screen combinations, the exposures range from 35 to 41 kV, or 10 to 20 mAs (magnification technique) and between 28 and 35 kV or 25–40 mAs (low-kilovoltage). The digital alternative of magnification radiography using fine-focus tubes (direct radiographic magnification [DIMA] technique) is discussed in Chapter 2.

Special Imaging Techniques Radiographs of the Entire Hand As survey views, these include the distal section of the forearm, the carpus, the metacarpus, and all fingers. In addition to the dorsopalmar view (Fig.1.1 a), an oblique view is exposed as a second plane, namely the 45° semipronated oblique view (zither-player projection, Fig.1.1 b) and the 45° semisupinated oblique view (Nørgaard projection, Fig.1.1 c). Indications for a survey view of the hand are acute injury distal of the carpus, diagnosis of inflammatory joint diseases (often with the Nørgaard projection as the second plane), and diagnosis of systemic bone diseases, using the hand as an indicator.

a Dorsopalmar

Diagnosis of congenital abnormalities of the hand and determination of the skeletal age are performed with the dorsopalmar projection only.

Radiographs of the Wrist Indications for radiographic imaging of the wrist in two planes are pathologies of the distal forearm, the wrist, and the carpus. These include acute traumas, carpal instability, chronic degenerative and inflammatory diseases of the joints, and equivocal complaints at the wrist.

b Semipronated oblique

Fig. 1.1 a–c Positioning methods for radiographs of the entire hand.

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c Semisupinated oblique

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Table 1.1 Positioning methods for radiographs of the entire hand View

Position

Dorsopalmar

U

U

Semipronated oblique (zither-player position) Semisupinated oblique (Nørgaard)

U

U U

U

U

Alignment

Place the palm on the cassette with fingers slightly splayed Middle finger points along the longitudinal axis of the forearm Place the palm on a 45° wedgeshaped cushion Fingers spread like a fan Fingertips touch the cassette Place the back of the hand on a 45° wedged cushion Spread the fingers like a fan

U U

U U

U U

Perpendicular to the cassette Align to the metacarpophalangeal joint III Perpendicular to the cassette Align between metacarpophalangeal joints II and III Perpendicular to the cassette Align between metacarpophalangeal joints II and III

For radiologic diagnosis, an exact analysis of the radiograph of the distal section of the forearm and the carpus is only possible when the anatomical position is identical in both projection planes, i.e., without pronosupination between the two exposures. The so-called neutral position, which is the middle rotation of the forearm between the extreme positions of pronation and supination (Fig.1.2 c–e), is best suited to this purpose. Standardized radiographs of the wrist in neutral position have the following prerequisites: U For the dorsopalmar view, the upper arm is abducted 90° in the shoulder and placed on a positioning block so that the forearm and the hand are at shoulder level with the elbow flexed (Fig.1.2 a). U For the lateral view, the upper arm is adducted in the shoulder and the elbow is flexed 90° so that the forearm and the ulnar edge of the hand lie on the Bucky table (Fig.1.2 b). A rotational movement of 90° must be avoided when acquiring the views in two planes.

Quality Criterion U

U

U

U

U

Entire hand and distal part of forearm included

Metacarpals are seen largely free of superimposition Phalanges are seen completely free of superimposition Metacarpals are seen largely free of superimposition Phalanges are seen completely free of superimposition

The particular height between the abducted arm and the Bucky table is achieved for each patient individually by the use of a positioning block of appropriate height. Whether the radiographs have been taken in neutral position without rotational movements in the proximal and distal radioulnar joints can be ascertained by the following radiological signs: U The ulnar styloid only appears in profile on the outer edge of the head of the ulna if the hand is in the neutral position (Fig.1.2 f). In all other positions, the styloid process appears in an “en-face” projection, namely in pronation at the level of the ulnar section and in supination in the middle of the head of the ulna. U Pronosupination changes the apparent length of the radius and ulna (translatory shift). In pronation, the ulna is in a more distal position in relation to the radius, whereas it is located more proximally in supination.

Table 1.2 Positioning methods for radiographs of the wrist and the radiocarpal joint View

Position

Dorsopalmar

U U

U

Lateral

U U

U

Alignment

Arm abducted Palm at shoulder level on the positioning block Middle finger lengthens axis of forearm Arm adducted Ulnar edge of the hand positioned vertically on the Bucky table Place back of hand on perpendicular positioning aid

U U

U U

Perpendicular to the cassette Align to the middle of the radiocarpal joint

Perpendicular to cassette Align to the middle of the radiocarpal joint

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Quality Criterion U

U

U U

Ulnar styloid in profile on the outer edge of the head of the ulna

Pisiform projects halfway between distal pole of the scaphoid and the capitate Radius and ulna overlap Metacarpals II–V overlap

Special Imaging Techniques

Fig. 1.2 a–g Positioning methods and schematic diagrams for radiographic views of the radiocarpal joint and the wrist. a Dorsopalmar view with the hand positioned at shoulder height. b Position for the lateral view of the wrist. Adduction of the upper arm and placement of the back of the hand against a vertical positioning aid

lateral dv

dv P

N

N

c Articulation of the distal radioulnar joint during a dorsopalmar view in neutral position. Notice the congruence of the joint surfaces. The arrow symbolizes the central ray.

dv

d Articulation of the distal radioulnar joint during lateral view with the wrist in neutral position. The joint surfaces remain congruent. The arrow symbolizes the central ray.

e Articulation of the distal radioulnar joint during dorsopalmar view with the hand pronated. The joint surfaces are no longer congruent. The arrow symbolizes the central ray.

f Dorsopalmar view of the wrist in neutral position. Note the ulnar styloid process in lateral profile. g Lateral view of the wrist in neutral position. The palmar aspect of the pisiform projects halfway between the front of the capitate and the distal pole of the scaphoid.

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The Scaphoid Quartet Series The scaphoid appears shortened in standard projections because of its oblique alignment. When a fracture or nonunion of the scaphoid bone is suspected, and for followup, scaphoid quartet views can be acquired to complement the standard films of the carpus. The aim of the scaphoid series is to align the scaphoid parallel to the film plane insofar as possible. Radiographs of the scaphoid series are taken in four different exposures with dedicated positioning of the wrist, as well as alignment of the central ray (Fig.1.3 a–d). The focus is on the radial side of the carpus.

Together with the standard views, complete projection radiography of the scaphoid comprises six radiological settings. Stecher’s view is the most reliable of the quartet series for diagnosis of a scaphoid fracture. It has proved efficient in diagnosing fractures or nonunions to complement standard films only with a Stecher’s projection. Afterwards, the indications for additional diagnostic imaging with computed tomography (CT), magnetic resonance (MR) imaging, or both, should be considered. For further procedures, see Chapters 18 and 19.

Fig. 1.3 a–d Positioning methods for the scaphoid quartet series. a Position for Stecher’s projection: closed fist and ulnar inclination. b Position for Schreck’s projection: quill-holding position on a 45° wedge. c Position for Bridgeman’s projection: extension with the palm lying on a 30° wedged pad. d Position for the hyperpronation projection: closed fist and ulnar side elevated on a 30° wedged pad. a

b

c

d

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Special Imaging Techniques

Table 1.3 Positioning method for radiographs of the scaphoid (quartet series) View

Position

Stecher’s projection

U U U

Schreck’s projection Bridgeman’s projection Hyperpronation

U

U

U U

Alignment

Fist closed, thumb outside Maximal ulnar inclination Place the palmar side of the fist on the cassette Oblique position (quill-holding position) with hand placed on 45° wedged pad Place palm in extension on 30° wedged pad Closed fist and ulnar inclination Palm placed on 30° wedged pad

U U

U U

U U

U U

Quality Criterion

Perpendicular to cassette Align to the radial third of the carpus Perpendicular to cassette Align to the radial third of the carpus Perpendicular to table surface Align on the radial third of the carpus Perpendicular to cassette Align on radial third of carpus

Radiographs of the Other Carpal Bones

U

U

The five most important of the many projections described in the literature are discussed below. It is recommended to limit special projections of the wrist to two or three and then, if necessary, to proceed to CT or MRI. Special radiographs of the carpus are indicated for the following reasons:

U

U

U

U U

U

Scaphoid shown in its entire length

Scaphoid tuberosity visualized

Proximal scaphoid pole shown Scaphocapitate joint seen free of superimposition Scaphoid is straight along the longitudinal axis of the forearm

To determine the effective width of the scapholunate joint space by taking Moneim’s swear-hand view (Fig.1.4 a). To confirm suspicion of a fracture of the triquetrum with the semipronated oblique view (“triquetrum special”) (Fig.1.4 b). For diagnosis of a fracture of the pisiform and, especially, osteoarthritis of the pisotriquetral joint with the semisupinated oblique view (“pisiform special”) (Fig.1.4 c).

Table 1.4 Positioning method for special radiographs of the wrist View Swear-hand view (“Moneim”) Semipronated oblique view (“triquetrum special”) Semisupinated oblique view (“pisiform special”) Axial oblique view (“trapezium special”) Carpal tunnel view

Position

Alignment

U

Fingers IV and V flexed Place palm with flexed fingers IV and V on cassette

U

Place palm on 45° wedged pad

U

U U

U U

U

U

U U

U

U

U

Place back of hand on 60° wedged pad Slight extension Thumb abducted Place thumb laterally on cassette Place cushion under finger Traction loop around the fingers and metacarpus Tension on the loop provides maximal extension

U U

U U

U

U

Perpendicular to cassette Align to the middle of the radiocarpal joint Perpendicular to cassette Align to ulnar third of carpus

Perpendicular to cassette Align to ulnar third of carpus

Perpendicular to cassette Align to distal third of carpus

X-ray tubes angled at 45° from distal to proximal Align on the base of metacarpal III

Quality Criterion U

U

U

U

U

U

U

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Maximal width of scapholunate joint Dorsal side of triquetrum shown tangentially

Pisotriquetral joint seen free of superimposition

Both sesamoid bones overlap

Trapezium tuberosity seen free of superimposition Hook of hamate seen free of superimposition Pisiform seen free of superimposition

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a

b

d

e

c

Fig. 1.4 a–e Positioning methods for special radiographs of the other carpal bones. a Position for the Moneim swear-hand view; free projection of the scapholunate gap. b Position for the semipronated oblique view (“triquetrum special”). c Position for the semisupinated oblique view (“pisiforme special”) d Position for Kapandji’s axial oblique view (“trapezium special”). e Position for the inferosuperior carpal tunnel view.

U

U

To obtain a survey view of the trapezium and the adjacent scaphotrapeziotrapezoid (STT) joint and the carpometocarpal joint I with Kapandji’s axial oblique view (“trapezium special”) when a trapezium, Bennett, or Rolando fracture or osteoarthritis of the STT joint or the carpometacarpal joint I is suspected (Fig.1.4 d). To exclude stenosis of the carpal tunnel when carpal tunnel syndrome is present clinically. The socalled “carpal tunnel views” (superoinferior and inferosuperior) provide only limited information in comparison with cross-sectional images acquired with CT or MRI (Fig.1.4 e).

Radiological Stress Views of the Carpus and Thumb The integrity of the ligaments is tested with stress views. Increased mobility between two articular opponents provides indirect information about the condition of the stabilizing ligaments. If results are equivocal, the other hand should be examined to provide a comparison. U Stress views of the carpus are either active (the examined hand applies its own muscular strength) or passive (the noninjured hand or the examiner’s hand applies traction). The most common clinical questions in carpal instability concern the scapholunate ligament and the dynamic form of the ulnocarpal impaction

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Special Imaging Techniques

syndrome. Both questions can be answered simply by a dorsopalmar stress view with the injured hand gripping a ball tightly (Fig.1.5 a). The other stress views of the carpus (Fig.1.5 b–e) are only for special indications.

a

U

The stress view of the first metacarpophalangeal joint is taken while the examiner applies traction to the radial side of the thumb (Fig.1.5 f). The examiner wears a lead coat and gloves while performing the stress view of the thumb.

b

c

f

d

e

Fig. 1.5 a–f Positioning methods for stress views of the wrist and the thumb. a Stress position for the dorsopalmar grip view. b Stress position for the dorsopalmar view in ulnar inclination. c Stress position for the dorsopalmar view in radial inclination. d Stress position for the lateral view in extension. e Stress position for the lateral view in flexion. f Stress position of the thumb held in radial traction to the metacarpophalangeal joint.

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Table 1.5 Positioning methods for stress radiographs of the wrist and thumb Stress view

Position

Gripping ball

U U

Radial inclination Ulnar inclination Flexion

U U

U U

U

U

Extension

U

U

Radioduction of the thumb ray

U

U

U

Alignment

Tennis ball held tightly Place gripping hand on cassette Place palm on cassette Maximal radial inclination

U U

U U

Place palm on cassette Maximal ulnar inclination

U U

Place ulnar side of hand on cassette Maximal flexion Place ulnar side of hand on cassette Maximal extension Place cushion under palmar side of thumb Place palmar side of thumb on cassette Examiner puts ulnar stress on first metacarpophalangeal joint

U U

U U

U U

Quality Criterion

Perpendicular to cassette Align to the middle of the carpus Perpendicular to cassette Align to middle of carpus Perpendicular to cassette Align to middle of carpus Perpendicular to cassette Align to middle of carpus Perpendicular to cassette Align to middle of carpus Perpendicular to cassette Align to first metacarpopharyngeal joint

Radiographs of the Metacarpal Region These are acquired for detection and follow-up of fractures of the metacarpal bones. Radiographs are focused on an area covering the distal row of the carpus to the proximal phalanges in dorsopalmar (Fig.1.6 a) and semipronated oblique views (Fig.1.6 b). If a palmar deviation of the axis of the distal fragment is suspected, a strictly lateral film must also be taken. The Brewerton projection (Fig.1.6 c) is useful for assessment of the metacarpophalangeal joints II to V with traumatic or inflammatory changes. This view provides good visualization of the grooved transition on the outer aspect of the metacarpal head to the bony attachment of the collateral ligaments.

U U

U U

U U

U U

U U

U

Ulnar styloid process in profile Lunate bone appears as triangle “Ring sign” of the scaphoid “High position” of triquetrum Full length of scaphoid “Low position” of triquetrum Radius and ulna overlap Metacarpals II–V overlap Radius and ulna overlap Metacarpals II–V overlap Thumb shown in strict dorsopalmar position

Radiographs of the Thumb and Finger Survey views of the entire hand are taken for diagnosis of systemic inflammatory diseases, such as rheumatoid arthritis (Chapter 36), and in the acutely injured hand. Special views are needed for subtle assessment of thumb and finger joints (Fig.1.7 a–d). Requirements include focusing the central ray on the diseased finger joint and a strictly lateral projection in the second plane. Indications for special radiographs of the finger are an intra-articular fracture and the presurgical diagnosis of Heberden’s and Bouchard’s osteoarthritis, as well as congenital abnormalities of the finger joints (such as camptodactyly and clinodactyly). Intra-articular fractures of the fingers occasionally require a third radiographic projection with an oblique beam path for evaluation of the joint contours (Fig.1.7 e).

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Special Imaging Techniques

a

b

c

Fig. 1.6 a–c Positioning methods for radiographs of the metacarpus and the metacarpophalangeal joints. a Position for the dorsopalmar view. b Position for the semipronated oblique view (zither-player projection). c Position of the metacarpophalangeal joints II to V in the Brewerton projection.

a

b

c

d

e

f

Fig. 1.7 a–f Positioning methods for radiographs of the thumb and fingers. a Position for the palmodorsal view of the thumb. b Position for the lateral view of the thumb. c Position for the dorsopalmar view of a finger. d Position for the lateral view of a finger. e Dorsopalmar view of a finger with correct visualization of the proximal interphalangeal joint space. f Lateral view of a finger with complete overlapping of the condyles of the middle phalanx.

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Further Reading Birkner R. Das typische Röntgenbild. Munich: Urban & Schwarzenberg; 1977:258–285. Brewerton DA. A tangential radiographic projection for demonstrating involvement of metacarpal heads in rheumatoid arthritis. Br J Radiol. 1967;40:233–234. Epner RA, Bowers WH, Guilford WB. Ulna variance: The effect of wrist positioning and roentgen filming technique. J Hand Surg. 1982;7: 298–305. Hardy DC, Totty WG, Reinus WR, Gilula LA. Posteroanterior wrist radiography: Importance of arm positioning. J Hand Surg. 1987;12A: 504–508. Jedlinski A, Kauer JM, Jonsson K. X-ray evaluation of the true neutral position of the wrist: The groove for extensor carpi ulnaris as a landmark. J Hand Surg. 1995;20A:511–512. Kindynis P, Resnick D, Kang HS, Haller J, Sartoris DJ. Demonstration of the scapholunate space with radiography. Radiology. 1990;175: 278–280. Levis CM, Yang Z, Gilula LA. Validation of the extensor carpi ulnaris groove as a predictor for the recognition of standard posteroanterior radiographs of the wrist. J Hand Surg. 2002;27A:252–257. Linn MR, Mann FA, Gilula LA. Imaging the symptomatic wrist. Orthop Clin North Am. 1990;21:515–543. Mann FA, Wilson AJ, Gilula LA. Radiographic evaluation of the wrist: What does the hand surgeon want to know? Radiology. 1992;184: 15–21. Moneim MS. The tangential posteroanterior radiograph to demonstrate scapholunate dissociation. J Bone Joint Surg. 1981;63A: 1324–1326. Norgaard F. Earliest roentgenological changes in polyarthritis of the rheumatoid type: Rheumatoid arthritis. Radiology. 1965;85: 325–329. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg. 1982;7:376–379. Saffar P. Carpal Injuries. Anatomy, Radiology, Current Treatment. Heidelberg: Springer; 1990:17–27.

Schernberg F. Roentgenographic examination of the wrist: A systematic study of the normal, lax and injured wrist. Part 1: The standard and positional views. J Hand Surg. 1990;15B:210–219. Schernberg F. Roentgenographic examination of the wrist: A systematic study of the normal, lax and injured wrist. Part 2: The stress views. J Hand Surg. 1990;15B:220–228. Sonmez M, Turaclar UT, Tas F, Sabanciogullari V. Variation of the ulnar variance with powerful grip. Surg Radiol Anat. 2002;24:209–211. Stecher WR. Roentgenography of the carpal navicular bone. Am J Roentgenol. 1937;37:704–705. Taleisnik J. The Wrist. New York: Churchill Livingstone; 1985:79–104. Tomaino MM, Rubin DA. The value of the pronated grip view radiograph in assessing dynamic ulnar positive variance. Am J Orthop. 1999;28:180–181. Toth F, Mester S, Cseh G, Bener A, Nyarady J, Lovasz G. Modified carpal box technique in the diagnosis of suspected scaphoid fractures. Acta Radiol. 2003;44:319–325. Totty WG, Gilula LA. Imaging of the hand and wrist. In: Gilula LA, ed. The Traumatized Hand and Wrist. Philadelphia, Pa: Saunders; 1992: 1–18. Truong NP, Mann FA, Gilula LA, Kang SW. Wrist instability series: Increased yield with clinical-radiologic screening criteria. Radiology. 1994;192:481–484. Wicke L. Röntgendiagnostik. Einstelltechnik. Munich: Urban & Schwarzenberg; 1983:418–433. Wilson AJ, Mann FA, Gilula LA. Imaging the hand and wrist. J Hand Surg. 1990;15B:153–167. Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapitate alignment: Criterion to establish a neutral lateral view of the wrist. Radiology. 1997;205:865–869. Yin Y, Mann FA, Gilula LA. Positions and techniques. In: Gilula LA, Yin Y, eds. Imaging of the Wrist and Hand. Philadephia: Saunders; 1996:93–158. Zimmer EA, Zimmer-Brossy M. Lehrbuch der Röntgendiagnostischen Einstelltechnik. 3rd ed. Heidelberg: Springer; 1982:74–97. Ziter FM. A modified view of the carpal navicular. Radiology. 1973;3: 706–707.

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Special Radiographic Procedures R. Schmitt, S. Froehner

Digitally acquired projection radiographs can be postprocessed and transmitted electronically by a picture archiving and communication system (PACS) and filed. For diagnosis of skeletal abnormalities, digital luminescence radiography with phosphorus storage screens, as well as digital image-intensifier cinefluorography, is employed. Direct radiography with flat-panel detectors, which at present is not widely used, is a very promising method. Magnification techniques for high-definition images can demonstrate early stages of inflammatory and metabolic diseases.

Magnifying radiography with mammography films and the direct radiographic magnification (DIMA) technique are available for this purpose. Inflammatory changes of soft tissue can be visualized with low-kilovoltage radiography with a tube current of 28–30 kV. All these methods are reserved for special indications. Conventional tomography with multidimensional blurring figures is no longer used. Pathologic movements in dynamic carpal instabilities can be documented at high temporal resolution with cineradiography.

Digital Radiographic Procedures Aside from the sectional imaging techniques of ultrasonography, computed tomography (CT), and magnetic resonance (MR) imaging, digital imaging systems are also employed with increasing frequency in projection radiography. The typical characteristic of all digital techniques is the separation of the process of acquisition of the signal from the object under examination and the display of the signal as a luminance distribution in a computer system. The following quality parameters in combination provide good perception of image details. U The resolution and thereby the image definition are limited by the image matrix and the pixel size. In comparison to film–screen systems, digital imaging techniques are characterized by reduced spatial resolution. The spatial resolution of digital systems depends on the size of the matrix and the image format employed. To ensure good diagnostic detail recognition of bony structures, 2K systems (image matrix 2048 × 2048) are recommended for projection radiography of the hand. A matrix of 2048 × 2048 in a cassette format o f 18 × 24 cm results in a resolution of 5 line pairs (Lp)/mm, and in a cassette format of 24 × 30 cm gives resolution of 3.3 Lp/mm. In comparison, conventional film–screen systems deliver a spatial resolution between 5 and 8 Lp/mm. U This is contrasted with the advantages of improved contrast resolution of digital imaging systems. Digital images are generally stored with an image depth of 10 or 12 bytes/pixel. Digitally acquired images offer the possibility of subsequent postprocessing of the bright-

U

ness and contrast. Overlapping of the image signal by interference signals (noise) is primarily caused by quantum mottle. A direct relationship exists between the noise and the applied dose. Further advantages, apart from postprocessing, are the possibilities of telecommunication, making a diagnosis on the monitor, and filing without film on RAIDarray storages, laser disks, and tape recorder in a picture archiving and communication system (PACS). Alternatively, a hard copy can be made. The three different imaging systems in digital projection radiography are explained below.

Digital Luminescence Radiography (DLR) The Principle In digital luminescence radiography, the film–screen system is replaced as a data-storage medium by a storage screen, which, for example, consists of a layer of phosphorus compound. Special cassettes with formats identical to those of conventional systems are required. The cassettes equipped with phosphorus storage screens can be exposed in conventional radiographic examination units, making the procedure economic. The radiographic absorption profile is saved as a temporary image by the activation of electrons to a higher energy level on the phosphorus screen. The read-out process involves scanning with a beam of a helium laser (Fig. 2.1). The energy

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2 Special Radiographic Procedures

storage screen

excited state

exposure

laser beam

readout

adhesion

luminescence

x-rays ground state

Fig. 2.1 Schematic representation of digital luminescence radiography. (Reproduced with with permission from Bunke et al., 2001.) Left Exposure of the phosphorus storage screen. The temporary image is produced on the storage screen by raising the phosphorus atoms to a higher energy level (point of adhesion). Right Readout of the image information by a helium laser beam producing luminescence that is enhanced by a photomultiplier tube and transformed into a digital image in levels of gray.

absorbed within the phosphorus crystals during x-ray exposure is released locally as luminescence according to the information in the virtual image. The distribution of the emitted light is stored as an electrical signal via photomultipliers. The digitally stored DLR images can be postprocessed on a computer work-station.

Technical Procedure Storage screens have high sensitivity for x-rays and, in principle, enable radiation exposure to be reduced. Since the signal-to-noise ratio decreases with lower doses, reduction of the dose in diagnostic imaging of the hand is only possible to a limited degree. Dose reductions of about 15 % can be achieved in follow-up radiography in traumatology and in pediatric radiography. Radiation quality and doses applied in digital luminescence radiography are generally comparable to those of the conventional film–screen technique. Images that have been over- or underexposed in the acquisition process can usually be corrected during postprocessing, since the characteristic gradation curve is linear over a large range in storage-screen systems. The linearity over a large range results of faulty exposure can thus be compensated. Difficulties in interpretation in skeletal imaging can be caused by overshoot artifacts in the immediate vicinity of materials used for osteosynthesis. Extinction phenomena, which in the worst case can mimic loosening of material or infection, may arise with metallic implants with low image resolution.

Indications Given its many advantages, digital luminescence radiography with storage screens is currently the favored imaging procedure in projection radiography of the musculoskeletal system. K2 systems with an image matrix of 2048 × 2048 are used for diagnosis of the hand.

Direct Radiography with Flat Detectors The Principle In addition to the phosphorus storage-screen technique, projection radiography with electronic flat detectors (semiconductors and flat-panel detectors) provides a further digital procedure for projection radiography. These systems employ either amorphous silicon or selenium as the detector. In silicon or selenium detectors, information about the absorbed x-ray profile is recorded directly, electronically enhanced, and transferred to an analog-todigital (A/D) converter (Fig. 2.2). Since an intermediate step of optical, electronic, or mechanical scanning is unnecessary, this technology is referred to as direct radiography. Direct radiography has superior quantum efficiency to other imaging systems, resulting in lower image noise at the same radiation dose. This improved quantum efficacy can potentially be used to reduce the radiation dose. In a further application, real-time images that enable digital fluoroscopy to be performed can be generated with the selenium and silicon detectors because of their active matrix.

Technical Procedure Positioning methods and x-ray exposures in direct radiography with flat detectors are the same as for conventional projection radiography. The exposure values are equivalent to the common kV and mAs values over wide ranges. After exposure on the flat-panel detector system, the digital image information is immediately available for postprocessing and channeling into a PACS environment. In routine use, the processing is rapid because of the absence of cassettes is an advantage. Static integration of the system into the Bucky table or the use of a wall-mounted cassette holder introduces limitations,

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Radiography with Mammography Films

Csl scintillator

Image-intensifying Radiography

a-Si sensor matrix

The Principle

amplifier/ multiplexer

A/D converter

address glass substrate

Fig. 2.2 Direct radiography with flat-panel detectors. (Reproduced with with permission from Bunke et al., 2001.) The x-ray pattern of a projection radiograph is taken on a stationary flat-panel detector system, which consists of a cesium scintillator and a matrix of amorphous silicon crystals. The image is directly stored in digital form via intermediate electronic information enhancement. A readout is unnecessary.

In digital image-intensifying radiography, image recording is performed with a CCD (charge-coupled device) camera, which is integrated into the image-intensifying unit of a fluoroscopy unit as a recording system. The prototype of digital image-intensifying radiography is digital subtraction angiography (DSA). The resultant image is immediately available on the monitor screen. The digital image acquisition makes postprocessing possible (e.g., mask subtraction, pixel shift, edge enhancement, adjustment of contrast and brightness).

Technical Procedure however, since both prevent mobile use with the use of individually placed cassettes.

Indications The advantages of improved image quality, exposure without cassettes, and digital image acquisition and archiving make flat-panel direct radiography the imaging technique of the future. The flat-panel technique is not widely employed at present because the complex production techniques for the crystals result in high investment cost.

Fluoroscopy of the hand is achieved with spot films or angiography series. For high-contrast musculoskeletal imaging (plain osseous and arthrographic series), a matrix size of 1024 × 1024 with a spatial resolution of 1.8–2.0 Lp/mm is generally sufficient. For minute bony lesions, an image matrix of 2048 × 2048 is desirable. Digital image-intensifying radiography makes it possible to reduce radiation dose, but this desirable effect in radiation hygiene is achieved at the cost of a reduced signalto-noise ratio and decreased detail recognition.

Indications Besides digital subtraction angiography, digital imageintensifying radiography is used for fluoroscopic analysis and documentation. Despite reduced spatial resolution, arteriography of the hand (Chapters 5 and 48), movement analysis of the wrist, and three-compartment arthrography (see Fig. 3.2) can be comfortably performed and documented.

Radiography with Mammography Films The Principle

Technical Procedure

Survey views of the entire hand are performed with a film–screen combination providing a sensitivity value of 200 in traumatology. To achieve greater detail resolution, a less-enhancing mammography film–screen combination with a sensitivity value of 25 can be used. At a tube focus size of 0.6 mm, the spatial resolution is 6–8 Lp/mm.

The mammography films, contained in special cassettes, are exposed on the Bucky table with a suspended abovetable unit (FFD 105 cm) without the use of a scatteredradiation grid. Typical exposure values are 55 kV and 6.4 mAs.

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2 Special Radiographic Procedures

Table 2.1 Indications for radiography with mammography films U U U

Initial stage of arthritis Initial stage of crystal deposition disease Discrete manifestation of diffuse or regional osteoporosis

Indications Because of their higher radiation dose requirements than those for standard films (up to eightfold greater), mammography film–screen combinations should be employed only when strictly indicated for the diagnostic purposes listed in Table 2.1.

Techniques in Magnification Radiography Increasing the distance between object and film enlarges the image at a constant film–focus distance. Decreasing the size of the tube focus can compensate for the resulting lack of sharp detail (Fig. 2.3). Because of the limited xray performance at a small focus, only thin objects can be examined with the magnification technique. The clinical objectives for imaging of the hand listed in Table 2.2 can generally be examined with the magnification technique. The magnification technique makes it possible to recognize even the smallest structural irregularities in the cortical and trabecular bone and demineralization at the subchondral bone plate, as well as inflammatory swelling of the soft tissues. Ultrafine-focus magnification imaging of soft tissues and osseous structures can be carried out with the Groedel or direct radiographic magnification (DIMA) technique.

a

b

F

c

F

Ob

f

Table 2.2 Indications for magnification radiography U U U U

Possibly pathologic finding in the survey radiograph Suspicion of nondislocated fracture (fissure) Initial stage of arthritis Inflammatory soft-tissue changes

Magnification Radiography with Mammography Equipment The Principle The X-ray focus of mammography equipment has a size of 0.1–0.4 mm. The object should be enlarged by at least a factor of 1.5 in the image plane. If the enlargements are made at a focus–film distance of 0.65 m and an object–focus distance of 0.34 m, the result is an enlargement factor of 2. Skeletal radiographs for investigation of the fine structure of the trabecular bone are performed with an aluminum filter. The conventional molybdenum filter is used to investigate abnormalities of the soft tissues.

Ob

Technical Procedure

Ob Hs

Ts

Hs

Fig. 2.3 a–c Parameters for image recording in magnification radiography. Influence of the position of the object (Ob) and the focus spot sizes (F and f) on the image size (represented as umbra or true shadow Ts) and the geometric blurring (represented as penumbra or half shadow Hs). a If the object (Ob) is close to the film and the focus is large (F), only slight geometric blurring and magnification result in the image (about 10 % at a FFD of 105 cm). b If the object is far from the film, the large focus F leads to geometric blurring, as well as to magnification of the image. c At the same distance between object and film as in b, a small focus (f) reduces the geometric blurring while achieving the same degree of magnification.

Depending on the symptoms, target and/or stress radiographs are taken. Since exposure times are long in comparison to those of standard radiographs, the hand being examined must be fixed and, if necessary, even held by the investigator (wearing a lead apron and lead gloves). According to the region under investigation, it may be necessary to shift the measuring chamber to an intermediate or remote distance from the body. For radiographs of the distal radioulnar joint and the carpus, the hand is brought into a neutral position by varying the height of the examination table.

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Low-kilovoltage Technique

Magnification Radiography with the DIMA Technique

x-ray microfocus

The Principle The DIMA technique is characterized by geometric direct magnification. The enlarged projection image on the receiving plane is achieved by positioning the patient far from the film. The special workstation enables geometric enlargement up to a factor of 9 with a spatial resolution of 22 Lp/mm. A very small focal spot is required to avoid geometric blurring at the edges. X-ray tubes controlled by microprocessors enable spot sizes between 20 and 130 µm (at least one-tenth of those in mammography) to be obtained. The resolution attained through direct magnification is largely independent of the resolution of the image-receiving system (Fig. 2.4) so that highly intensifying film–screen systems or phosphorus storage-screen systems can be employed. For this reason, magnification techniques can be advantageously combined with digital luminescence radiography (DLR). This combination can reduce the radiation dose, and postprocessing can be performed with display of an image resembling conventional films with enhanced edges.

higher dispersion of radiation scatter

radiation scatter on the image plane is considerably reduced → better contrast

Fig. 2.4 Diagram of the magnification technique in DIMA radiography. The system is characterized by a microfocus, which prevents geometric blurring despite magnification and reduces film blackening as a result of reduced radiation scatter.

Technical Procedure The vacuum in the tube is only produced before use. By using highly intensifying systems, the exposure values and thereby also the radiation dose are reduced. Grids are not necessary, since placing the patient far from the imaging plane allows most of the stray radiation to disperse in space. A further result is a gain in contrast. The focus must be adjusted exactly on the region of interest to avoid coarse blurring.

Indications The DIMA technique makes it possible to obtain detailed pictures of the finest osseous structures. Because of the high resolution, the magnification technique is ideally suited for diagnosis of inflammatory joint diseases in early stages, as well as of metabolic diseases. Rare indications are examinations of acute traumas and bone tumors.

Low-kilovoltage Technique The Principle

Technical Procedure

Owing to greater differences in absorption, the tissue categories of “bones,” “water-equivalent tissues” (skin, vessels, muscle, tendons, and tendon sheaths, ligaments, joint capsules, bursae), and “fatty tissue” can be differentiated in the images produced by low-kilovoltage radiography. The mammography technique is used in special projections.

The carpal and metacarpal regions must be examined separately from the finger, including the metacarpophalangeal joints, because of the different soft-tissue densities. The low-kilovoltage technique is performed with six views (Table 2.3). Either a nonscreen film (so-called industrial film) or a superdefinition film–screen combination (8 Lp/mm) is used. Exposure factors are determined manually: a tube current of 28 kV is used for fingers and one of 30 kV for the wrist and metacarpal regions. Since the focus–film

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2 Special Radiographic Procedures

Table 2.3 Projections in low-kilovoltage technique

U

Fingers II–V U Dorsopalmar U 25° radial-oblique U 25° ulnar-oblique Carpometacarpal region U Dorsopalmar U Oblique-palmar-dorsal, radial side of hand elevated 25° (Nørgaard view) U Lateral U

distance is reduced in oblique views, the mAs product can be reduced by one step in comparison to dorsopalmar projections. U

Normal Anatomy and Pathomorphology U

U

U

The cutis is thicker on the radial side of the finger than on the ulnar side. Fat and connective tissue, as well as blood vessels, can be recognized in the subcutis using the lowkilovoltage technique. In rheumatoid arthritis, subcutaneous edema can lead to an increased streaky or reticular absorption pattern in connective tissue and to venous dilatation. The periarticular soft tissues comprise articular cartilage, joint capsules, joint fluid, ligaments, and tendons and tendon sheaths, as well as the interosseous and lumbrical muscles of the metacarpophalangeal (MP) joints. Because their absorption levels are equivalent, these structures appear as a homogeneous mass in low-kilovoltage radiography. The normal values shown in Table 2.4 apply to the soft-tissue densities of the finger (Fig. 2.5 a, b).

The periarticular soft tissues of the carpus are maximally 2 mm thick (Fig. 2.5 c, d). The size of the sacciform recess on the distal radioulnar joint varies. Arthritic diseases of the joints lead to a widening and loss of sharp definition on the outer contours of soft tissues. Early arthritic changes are best recognized in oblique views since swelling of the capsules of finger joints is most frequently located dorsoulnar and that of the carpus dorsoradial. Inflammatory thickening of soft tissues of the MP joints displaces the interdigital fatty stripes distally. The tendon apparatus consists of extensor and flexor tendons and their tendon sheaths. In 25° oblique projections, the tendons extend beyond the bony structures by 1–2 mm. Synovitis can increase their distance from the proximal phalanges. In the subchondral bone plate, minimal erosions caused by arthritis are reliably revealed by lowkilovoltage radiography, as well as accompanying marginal osteoproliferation caused by enthesiopathic reactions.

Indications Low-kilovoltage radiography has decreased in importance with advances in high-resolution ultrasonography and MRI, especially since the procedure involves considerable radiation exposure because of the number of views that must be taken and the high radiation absorption. The use of this procedure is therefore limited to clinical objectives that cannot be fulfilled by conventional projection radiography and sectional imaging techniques. The most important indication is detection of early stages of arthritis, such as rheumatoid arthritis, seronegative forms of arthritis, and crystal deposition diseases.

Table 2.4 Normal values for the thickness (in mm) of the periarticular soft tissues of the fingers. (MP = metacarpophangeal, PIP = proximal interphalangeal) Female

Male

Projection

II

III

IV

V

II

III

IV

V

MP

dorsopalmar

3.9

4.2

2.6

2.6

4.6

4.2

3.1

2.6

25° ulnoradial

4.5

–

–

2.8

5.3

–

–

3.1

dorsopalmar

2.2

2.1

1.8

1.9

2.5

2.6

2.3

2.0

25° ulnoradial

3.1

2.9

2.2

1.5

3.9

3.5

2.7

1.6

25° radioulnar

2.9

3.1

2.8

3.0

3.0

3.4

3.7

3.5

PIP

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Low-kilovoltage Technique

a

A

1

C

B

2

D

1

2

E F

2

3

c

3 1

b

Fig. 2.5 a–d Normal and pathologic soft-tissues of the fingers and wrist. a Diagram of normal soft-tissue anatomy of the finger (Fischer 1982). Dorsopalmar low-kilovoltage radiography of the index and middle fingers. 1, sum of the periarticular softtissues (reduction in width from proximal to distal); 2, lateral portions of the extensor tendon; 3, subcutaneous veins. b Early stages of rheumatoid arthritis three months after onset of symptoms. The film with 25° elevation of the hand on the radial side shows expansion of periarticular soft-tissues in the proximal interphalangeal (PIP) joints, to a lesser degree in the metacarpophalangeal (MP) joints and distal interphalangeal (DIP) joints, as well as swelling of the flexor-tendon sheaths. The subcutaneous fatty tissue is thickened in a reticular pattern. (Courtesy of Dr. R. Hippeli, Stuttgart.) c Diagram of normal soft-tissue anatomy of the wrist (Fischer 1982). A, tendon sheath of the long abductor and the short extensor of the thumb; B, vein on the back of the hand; C, distal portion of the tendon of the extensor carpi ulnaris muscle; D, tendon sheaths on the palm, which are separated by fatty septa; E, extensor carpi ulnaris muscle (the segment continuing to C is often obliterated); F, sacciform recess of the distal radioulnar joint. d Carpal soft-tissue swelling in the early stage of rheumatoid arthritis (continued from b). The 25° Nørgaard view shows thickening of the tendon sheaths of the extensor carpi ulnaris muscle (large arrow), the ulnocarpal complex including the ulnar recess (small arrow), and, to a slight degree, the abductor pollicis longus muscle (arrowheads). (Courtesy of Dr. R. Hippeli, Stuttgart.)

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U

a

d

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2 Special Radiographic Procedures

Conventional Tomography The Principle With dedicated movements of the tomography x-ray unit, the effect of blurring in conventional tomography caused by movement is used for the selective depiction of static tissues. Those portions of the picture of no interest are blurred, while the diagnostically relevant details are depicted precisely. The x-ray tubes and the film are moved synchronously in opposite directions while the object in question remains stationary. Because of the radiation geometry, all parts of the object being investigated that lie in the center of rotation are motionless and are therefore always projected in the same place on the film. Using scanners with one-dimensional blurring, the focus–film system moves either plane parallel (planeparallel principle) or on segments of a circle (Grossmann principle) around the center of rotation. The advantage is shorter acquisition times of 0.5–1.0 second. In multidimensional blurring, the film–screen system performs a complex movement in plane-parallel levels or on circular segments (Fig. 2.6 a–g).

a

b

e

c

f

d

g

Fig. 2.6 a–g Blurred figures in conventional tomography. The imaging system can pass through the following figures: a Linear tomography d Figure eight b–g Multidirectional e Three concentric circles tomography f Trispiral b Circular g Hypocycloid c Elliptical

Indications

Technical Procedure For conventional tomography of the hand, a small X-ray focus, a tube current between 45 and 55 kV, and a slice thickness between 1 and 2 mm are selected. Multidirectionally blurred images are preferable to linear ones on the hand. An aluminum filter should be used on the fingers. Conventional tomography can be performed in dorsopalmar and lateral beam paths.

This method has largely been replaced by CT and MRI in the last few years. Tomography is used only if these sectional imaging techniques are not available.

Cineradiography The Principle Cineradiography provides evidence of abnormal movements of the wrist under fluoroscopic control. Since only the bony structures are visualized in fluoroscopy, cineradiography as a radiographic procedure can only provide indirect evidence of a ruptured ligament. Direct visualization of the damaged ligament is possible only with MRI and arthroscopy. The use of pulsed fluoroscopy reduces motion artifacts, as well as the radiation dose. Recording of the dynamic series of images can be carried out with a pulsed high-frequency camera, digital radiography (DSI, digital spot imaging), or a video camera: U The advantage of cineradiography with the highfrequency camera is the high rate of 50 images per second with very good definition, exceeding 10 Lp/mm. A disadvantage is that the 35 mm cineradiographic

U

U

film must be developed and evaluated with the use of a special unit. Cineradiography using digital radiography is most convenient in the daily clinical routine and has the lowest radiation requirement. Depending on the equipment, image acquisition is limited to 7.5–30 images per second. Twenty-five images per second can be acquired with video recording. The inferior spatial resolution becomes especially apparent when viewing with freezeframe.

Technical Procedure Cineradiography is conducted with pulsed radiation. The following parameters are set at the beginning of the procedure: voltage 55 kV, current 140 mA, pulse length 3 msec (if possible with the x-ray unit being used). While

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Cineradiography

Table 2.5 Indications for cineradiography U U U

U

Dynamic form of a carpal instability suspected Unclear posttraumatic restriction of mobility Postoperative control of function following suture of tendon or arthrodesis Motion analysis in osteoarthritis

Indications for Carpal Cineradiography The domain of this procedure is to provide evidence of dynamic articular malfunction or carpal instabilities (see Figs. 23.4 and 23.18). Further indications are listed in Table 2.5.

Further Reading

Fig. 2.7 Patient positioning for cineradiography. The high-frequency camera is attached to the image intensifier (upper portion of picture). The patient’s forearm is fixed in a grooved block. (Courtesy of H. Daschner, MD, Munich.)

the film is running, automatic exposure control is accomplished with a kV/mA servo control. The duration of filming varies between 5 and 50 seconds. For a cineradiographic examination the patient sits on the end of the fluoroscopy table (Fig. 2.7). The patient’s forearm is fixed to a positioning block in the neutral position so that the wrist of the hand being examined extends beyond the block. The carpus of the fixed and extended arm is adjusted precisely under fluoroscopic control. Hand movements are carried out at moderate speed. Each of the following projections is documented in 2–3 movement sequences: U Pattern of movement from radial inclination to ulnar inclination in a palmodorsal beam path. U Pattern of movement from flexion to extension in a lateral (ulnoradial) beam path. U To achieve maximum possible movement, combined movement sequences, which the patients know best and performs on their own, are often necessary.

Arkless R. Cineradiography in normal and abnormal wrists. Am J Roentgenol. 1966;96:837–844. Bond JR, Berquist TH. Radiologic evaluation of hand and wrist motion. Hand Clinics. 1991;7:113–123. Buckland-Wright JC, Bradshaw CR. Clinical applications of high-definition microfocal radiography. Brit J Radiol. 1989;62:209–217. Bunke J, Delorme S, Kamm KF et al. Physikalisch-technische Prinzipien der Bilderzeugung. In: Schmidt T, ed. Handbuch Diagnostische Radiologie. Strahlenphysik, Strahlenbiologie, Strahlenschutz. Vol 1. Heidelberg: Springer; 2001:1–161. Doyle AJ, Gunn ML, Gamble GD, Zhang M. Personal computer-based PACS display system: comparison with a dedicated PACS workstation for review of computed radiographic images in rheumatoid arthritis. Acad Radiol. 2002;9:646–653. Fischer E. Demonstration of wood and small glass splinters using softray. Fortschr Röntgenstr. 1973;118:309–312. Fischer E. Soft tissue changes of fingers in rheumatoid arthritis. Results of low k.v. radiographs in three views. Radiologe. 1979;19: 119–137. Fischer E. Soft tissue changes in the wrist in chronic polyarthritis. Results of weak-radiation exposures in 3 planes. Radiologe. 1985; 25:562–572. Heuck F, Schilling M. Informational value of weak-radiation immersion radiography of the hand in hormonal and metabolic osteopathies. Radiologe. 1985;25:573–581. Ho C, Sartoris DJ, Resnick D. Conventional tomography in musculoskeletal trauma. Radiol Clin North Am. 1989;27:929–932. Klein HM, Wein B, Langen HJ, Glaser KH, Stargardt A, Günther RW. Fracture diagnosis with digital luminescence radiography. Fortschr Röntgenstr. 1991;154:582–586. Krug B, Fischbach R, Herrmann S et al. X-ray studies of the peripheral joints: a comparison of digital luminescence radiography (DLR) and film-screen systems. Fortschr Röntgenstr. 1993;158:133–140. Link TM, Fiebich M, Gaubitz M et al. Value of direct radiographic enlargement (DIMA) in early detection of rheumatic inflammatory lesions. Comparative evaluation with high resolution conventional imaging technique. Radiologe. 1994;34:405–410. Linscheid RL, Dobyns JH, Young DK. Trispiral tomography in the evaluation of wrist surgery. Bull Hosp Joint Dis Ortho Inst. 1984;44: 297–308. Littleton JT. Conventional tomography in perspective. Radiographics. 1986;6:336–339. Müller RD, Buddenbrock B, Kock HJ et al. Digital luminescence radiography (DLR) for skeletal diagnosis in traumatology. Fortschr Röntgenstr. 1991;154:575–581. Murphey MD. Digital skeletal radiography: Spatial resolution requirements for detection of subperiostal resorption. Am J Roentgenol. 1989;152:541–546.

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Murphey MD, Bramble JM, Cook LT, Martin NL, Dwyer III SJ. Nondisplaced fractures: Spatial resolution requirements for detection with digital skeletal imaging. Radiology. 1990;174:865–870. Nielsen PT, Hedeboe J. Posttraumatic scapholunate dissociation detected by wrist cineradiography. J Hand Surg. 1984;9A:135–138. Norman A. The value of tomography in the diagnosis of skeletal disorders. Radiol Clin North Am. 1970;8:251–258. Posner MA, Greenspan A. Trispiral tomography for the evaluation of wrist problems. J Hand Surg. 1988;13A:175–181. Prokop M, Galanski M, Oestmann JW et al. Storage phosphor versus screen-film radiography: Effect of varying exposure parameters and unsharp mask filtering on the detectability of cortical bone defects. Radiology. 1990;177:109–113. Reuther G, Kronholz HL, Hüttenbrinck KB. Development and prospects of medical magnification radiography. Radiologe. 1991;31: 403–406. Sarrafian S, Melamed JL, Goshgarian GM. Study of wrist motion in flexion and extension. Clin Orthop. 1980;126:153–159. Smith DK, Linscheid RL, Amadio PC, Berquist TH, Cooney WP. Scaphoid anatomy: Evaluation with complex motion tomography. Radiology. 1989;173:177–180.

Stieve FE. Picture construction in tomography using uni- and multidimensional blurring. Fortschr Röntgenstr. 1972;116:253–265. Strotzer M, Volk M, Holzknecht N et al. Digital radiography of the skeleton using a large-area detector based on amorphous silicon technology: Image quality and potential for dose reduction in comparison with screen-film radiography. Clin Radiol. 2000;55: 615–621. Strotzer M, Volk M, Wild T, von Landenverg P, Feuerbach S. Simulated bone erosions in a hand phantom: Detection with conventional screen-film technology versus cesium iodide-amorphous silicon flat-panel detector. Radiology. 2000;215:512–515. Tehranzadeh J, Davenport J, Pais MJ. Scaphoid fracture: Evaluation with flexion–extension tomography. Radiology. 1990;176:167–170. Volk M, Paetzel C, Angele P et al. Routine skeleton radiography using a flat-panel detector: Image quality and clinical acceptance at 50 % dose reduction. Invest Radiol. 2003;38:230–235. Youm Y, McMurtry RY, Flatt AE, Gillespie TE. Kinematics of the wrist. An experimental study of radial-ulnar deviation and flexion– extension. J Bone Joint Surg. 1978;60A:423–431.

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3

Arthrography V. Metz, R. Schmitt, G. Christopoulos

The articular spaces of the radiocarpal joint and the wrist are visualized with arthrography. Three-compartment arthrography is recommended to achieve a complete view. In the first session the midcarpal and the distal radioulnar joint are examined, and in the second session the radiocarpal joint is examined. Because of age-dependent degeneration of the ligaments and the triangular fibrocartilage complex (TFCC), the spectrum of arthographic variations is

large. Conventional arthrography, which often correlates poorly with complaints, should therefore only be evaluated in the context of clinical findings. It is advantageous to combine arthrography and sectional imaging techniques in procedures termed MR arthrography or CT arthrography, both carrying the advantages of distension and optimal contrast of joint spaces with direct imaging of intra-articular soft tissues.

Anatomical Considerations As demonstrated in Table 3.1 and Fig. 3.1, the wrist consists of three large and numerous small synovial joint spaces (compartments). Normally, there is no communication among the three large articular spaces, whereas intercompartmental communication among smaller joint spaces sometimes occurs as a variation of normal anatomy. The midcarpal joint compartment (Fig. 3.2 a) extends between the proximal and distal carpal row and often communicates with the carpometacarpal and intermetacarpal joint spaces of phalanges II–IV. The distal radioulnar joint compartment (Fig. 3.2 b) is bounded by the proximal surface of the triangular fibrocartilage complex and extends to a variable degree proximally. The radiocarpal joint compartment in between (Fig. 3.2 c) is bounded proximally by the articular cartiTable 3.1 Compartments of the joints of the hand and fingers Large joint spaces U Midcarpal compartment U Radiocarpal compartment U Distal radioulnar compartment Small joint spaces U Carpometacarpal compartment I U Carpometacarpal compartments II–V U Intermetacarpal compartments II–V U Pisotriquetral compartment Finger joints U Metacarpophalangeal joints (proximal joints) U Proximal interphalangeal joints (middle joints) U Distal interphalangeal joints (distal joints)

MCJ

RCJ

DRUJ

Fig. 3.1 Diagram of the joint compartments of the carpus. The midcarpal joint (MCJ) and the distal radioulnar joint (DRUJ), which are filled with contrast medium in the first part of the examination, are shown in pink. The radiocarpal joint (RCJ) lies in between (not colored) and is examined in a second session. The pisotriquetral compartment, which is separate in one-third of cases examined, is not shown here.

lage of the distal radial section and the triangular fibrocartilage complex (TFCC). The distal boundary is the proximal carpal row and interosseous ligaments (scapholunate and lunotriquetral ligaments). In arthrography, the radiocarpal compartment has a C-shaped configuration with three recesses (Table 3.2).

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3 Arthrography

Arthrography of the Large Joint Spaces

Table 3.2 Recesses of the radiocarpal joint compartment U

U

Examination Technique Arthrography is performed in the prone position with the patient’s arms stretched above his or her head and the wrist in pronation. After application of local anesthesia, a 25G cannula is inserted into the appropriate joint cavity under sterile conditions and fluoroscopic control, and digital or analog imaging with 1 image per second are carried out. U In conventional and CT arthrography, a mixture of two parts water-soluble contrast medium and one part local anesthetic is injected. This mixture is injected under continuous fluoroscopic control until the patient reports feeling pressure. The diagnostic advantage of adding local anesthetic to the mixture is that a reduction in pain (pain testing) indicates a probable cause of wrist complaints in this compartment. U In MR arthrography, a gadolinium solution is added to the above mixture to produce a solution with a ratio of 200:1 x-ray contrast medium/local anesthetic to gadolinium contrast medium. All arthrographic accesses are on the dorsal side; the puncture site should always be chosen some distance from the reported painful area (Table 3.3). This is the only way to avoid confusing a capsule defect caused by puncture trauma with a pathologic condition. The following peculiarities must be mentioned: U In midcarpal arthrography with radial access, the puncture site must be as far distal as possible, because otherwise the radiocarpal compartment can be filled

U

U

U

Ulnar recess (prestyloid recess) – Lies palmar to the ulnar styloid process Palmar-radial recess – Lies palmar to the palmar lip of the radius – Next to the origin of the radioscapholunate ligament Dorsoradial recess – Lies dorsal to the dorsal lip of the radius

with contrast medium via its scaphoid recess, which extends far in a distal-dorsal direction. A volume of 1– 2 ml of contrast medium is generally sufficient. Due to the physiological inclination of the radial joint surface 10° in the palmar direction, it is advantageous to project the radiocarpal joint by tilting the x-ray tube in a superior–inferior direction. The same effect can be achieved with a positioning wedge under the wrist. Puncture of the tabatière (“snuff box”) should be avoided because the dorsal branch of the radial artery can be found here. Puncture between the scaphoid and the lunate bone should also be avoided, since the midcarpal compartment can be filled with contrast medium if a deep recess is present. A volume of 2–3 ml of the contrast mixture is injected. The distal radioulnar joint can hold about 1 ml of contrast medium.

Multicompartment Arthrography Incomplete (noncommunicating) defects can, under certain conditions, escape detection in single-compartment arthrography. For example, avulsion of the triangular

U

U

24

a

b

c

Fig. 3.2 a–c Normal arthrographic findings (digital intensifying radiography). a Arthrography of the midcarpal joint. The contrast medium extends from distally into the scapholunate and lunotriquetral articular spaces, but without entering the radiocarpal joint. b Arthrography of the distal radioulnar joint immediately after examination of the midcarpal joint. The arrow points to the

proximal surface of the ulnocarpal complex (TFCC, triangular fibrocartilage complex). c Arthrography of the radiocarpal joint in a second session. The contrast medium runs into the radiocarpal recesses joints. The arrow points to the distal surface of the ulnocarpal complex (TFCC).

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Arthrography of the Large Joint Spaces

Table 3.3 Accesses in arthrography of the wrist

Table 3.4 Three-compartment arthrography

Midcarpal arthrography U Ulnar access for complaints on the radial side: at the junction of the lunate/triquetral and capitate/ hamate joints U Radial access for complaints on the ulnar side: between the scaphoid and the head of the capitate

First procedure Midcarpal arthrography and arthrography of the distal radioulnar joint Second procedure Radiocarpal arthrography two hours later

Distal radioulnar arthrography U Proximal at the radial edge of the head of the ulna

MR Arthrography and CT Arthrography

Radiocarpal arthrography U Ulnar access for complaints on the radial side: at the level of the lunotriquetral joint U Radial access for complaints on the ulnar side: at the level of the radioscaphoid joint

fibrocartilage complex from its proximal ulnar attachment on the styloid process will not be seen if the arthrographic examination is limited to the radiocarpal joint. For this reason, the arthrographic examination should include all three large compartments. With nonspecific complaints concerning the wrist, only visualization of all articular spaces can reveal communicating and noncommunicating defects. Performance of three-compartment arthrography is therefore justified, particularly since defects can be present in several compartments. The suitable injection sequence for this examination is shown in Table 3.4. This procedure offers the advantage of showing all joint compartments without overlapping, since the contrast medium injected in the first session is absorbed during the two-hour interval. By applying the digital subtraction technique during the injection, all compartments can be examined in immediate succession. However, arthrographic stress films cannot be acquired with the subtraction method.

Documentation

Sectional imaging diagnosis with MR arthrography or CT arthrography is conducted immediately after arthrographic filling of the joint spaces. The time between arthrography and MRI or CT should be kept as short as possible to prevent the intra-articular contrast medium from diffusing into the surrounding soft tissues. The sequence protocols of MR arthrography are introduced in Chapter 9. CT arthrography is done in the axial scan plane on a spiral scanner, preferably with the multislice technique. Afterwards the coronal and sagittal multiplanar reconstruction (MPR) slices are performed (Chapter 8).

Communicating Pathways U

U

U

After removal of the puncture needle, stress films are produced under fluoroscopic control. Experience has shown that defects in the interosseous ligaments, the triangular fibrocartilage complex, and the joint capsule are often revealed only during wrist movements. Documentation includes standard films in pronation, in supination, and in radial and ulnar inclination, when the scapholunate and lunotriquetral joint spaces must be projected in profile for optimal assessment of the interosseous ligaments. Whether a communicating defect involves the whole circumference or only a portion (pinhole defect) of an interosseous ligament can best be determined with additional views taken during flexion and extension of the wrist.

U

Defects in ligaments, joint capsules, and the triangular fibrocartilage complex can be communicating (joining two neighboring compartments) or noncommunicating (no intercompartmental communication). Bi-directional defects are usually complete defects that are revealed in each injection into neighboring compartments. For example, rupture of the scapholunate ligament is revealed when contrast medium is injected into the midcarpal compartment, as well as into the radiocarpal compartment. These defects generally lead to mechanically relevant disturbances in kinematics of the involved bones. A unidirectional defect (Fig. 3.3 a–c) is an incomplete lesion that can only be seen from one compartment because of a valve effect. A unidirectional defect can, of course, be overlooked in single-compartment arthrography. A special form is the “pinhole” defect. It resembles a buttonhole in the interosseous ligaments of the proximal row of carpal bones and most often affects the central (membranous) segment of the scapholunate ligament and the lunotriquetral ligament.

Variants and Lesions U

Arthrographic variants are seen on the scapholunate ligament, whose clinical relevance is not entirely clear. As demonstrated in Fig. 3.4, this arthrographic finding often cannot be definitively classified as a variant of

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3 Arthrography

SL

a

c

b

Fig. 3.3 a–c Unidirectional defect of the scapholunate ligament. a Filiform flow of contrast medium into the radiocarpal joint (arrow) during arthrography of the midcarpal joint. b During subsequent arthrography of the radiocarpal joint, no overflow of contrast medium is seen (curved arrow); the ligament appears intact. c Diagram to accompany a and b; SL = scaphoid ligament.

U

U

U

the norm, a partial rupture of the ligament, or a posttraumatic scar. Different forms of communicating and noncommunicating defects can be found in the scapholunate and lunotriquetral ligaments (Table 3.5, Fig. 3.3). These defects can occur with or without widening of the involved joint space. Communicating defects between the midcarpal and radiocarpal compartments can be of traumatic, inflammatory, or degenerative origin. It should be remembered that degenerative intercompartmental communications are already evident from the age of 30 or 40 years and increase considerably in incidence with increasing age. Ninety percent of the normal population in their sixties have degenerative intercompartmental communications. Additionally, correlation between clinical symptoms and arthrographically diagnosed lesions is either poor or nonexistent. For this reason, the clinical significance of arthrographic findings from the fourth decade of life onward is uncertain and requires careful clinical assessment. Small, isolated deposits of contrast medium with sharp contours can be seen on the proximal or distal surface of the triangular fibrocartilage complex in 12 % of arthrograms. These are synovial recesses, which should not be misinterpreted as incomplete perforations. Palmer’s classification of lesions of the triangular fibrocartilage complex into traumatic (Class I) and degenerative (Class II) defects has proved useful. Chapter 18 provides more detailed information. Arthrographic differentiation between these two types of defects is often difficult, as physiologic degenerative changes in ligaments, as well as in the triangular fibrocartilage complex, can already be found among 30-year-olds. Arthrographic results should,

U

therefore, be evaluated only in close comparison with clinical findings. The ulnar (prestyloid) recess can be evaluated well with arthrography. This recess can best be evaluated in strict lateral views and in oblique views in supination after arthrography. Abnormality of this recess causes pain on the ulnar side of the wrist. Such complaints arise in connection with inflammatory and degenerative joint diseases (Chapter 29).

Fig. 3.4 Abnormal depth of the scapholunate compartment. After injection into the midcarpal joint, the contrast medium flows much further than normal into the scapholunate joint space (arrow). Is this a variant of the norm or a loose ligament?

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Arthrography of the Small Joint Spaces

Arthrography of the Small Joint Spaces The small joint spaces are the pisotriquetral joint compartment and the saddle joint of the thumb (carpometacarpal joint I).

Arthrography of the Pisotriquetral Joint

U

U

The pisotriquetral articulation is surrounded by a synovial space. A third of all hands have a closed synovial space with no communication with the radiocarpal or midcarpal joint compartment. In the rest, the synovial space communicates with the radiocarpal joint compartment. The small compartment between the pisiform and the triquetrum generally has very narrow proximal and distal recesses. Arthrography of the pisotriquetral joint is rarely indicated. Indications are early-stage deforming osteoarthritis, which is not detected in sectional imaging techniques, and localized chondromatosis of the joint. The ulnar access is best for arthrography of this joint. Puncture can prove difficult, even with the help of fluoroscopy, as the joint cavity is very narrow. Spot films are taken, preferably in an oblique, supinated projection, with which the pisotriquetral articulation can be seen in its entirety.

a

Table 3.5 Lesions of the scapholunate and lunotriquetral ligaments Unidirectional type Communication only from the midcarpal or radiocarpal side – “Flaplike” lesion Bidirectional type Communication from the midcarpal and radiocarpal side: – Entire ligament is affected – Only part of the ligament is affected – Special form: “pinhole” defect

Arthrography of the Saddle Joint of the Thumb Because MRI offers good diagnostic possibilities, arthrography of carpometacarpal joint I is an exception. The joint is punctured from dorsal or radial under fluoroscopic control. The surface of the articular cartilage and the integrity of the capsule ligaments are evaluated. By adding local anesthetic to the injected mixture, pain testing for early osteoarthritis of the saddle joint can be performed.

b

c

Fig. 3.5 a–c Normal findings in MR arthrography of the wrist with the two-compartment technique. a Arthrography of the radiocarpal joint with injection of a mixture of iomeprol and gadolinium-DPTA (200:1) following puncture of the radioscaphoid joint compartment. b Arthrography of the midcarpal joint following puncture of the midcarpal compartment where the lunate, triquetral, capitate and hamate bones meet.

c Coronal MR arthrography with a T1-weighted SE sequence. The scapholunate and lunotriquetral ligaments, as well as the distal surface of the triangular fibrocartilage (TFC), appear intact. The proximal surface of the TFC cannot be evaluated.

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3 Arthrography

a

b

Fig. 3.6 a–c MR arthrography of metacarpophalangeal (MP) joint III. a Puncture of MP joint III on the ulnar side under fluoroscopic control with a 24-gauge cannula. b Projection of the joint after removal of the cannula. The joint recess, which extends proximally, becomes visible. c Sagittal MR arthrography with a fat-saturated T1-weighted SE sequence.

c

Arthrography of the Finger Joints Arthrography of the finger joints is performed to assess the capsule ligaments, including the collateral ligaments and the palmar plate. If chronic joint instability is suspected, this procedure can determine whether there is a loose joint capsule following traumatic joint distension. The metacarpophalangeal joints are generally examined with arthrography. The finger joints are punctured with

an oblique dorsal access under fluoroscopic control, and 0.5–1.5 ml of contrast medium is injected (Fig. 3.6 a). After removal of the cannula, spot films with tangential imaging of the injured segment of the capsule are performed (Fig. 3.6 b). A combination of phalangeal arthrography with high-resolution MRI is advantageous (Fig. 3.6 c).

Indications and Assessment Table 3.6 lists the most common indications. The compilation covers only conventional arthrography. The spectrum of indications is enlarged by MR arthrography or CT arthrography, both of which are better than

nonarthrographic CT and MRI for detection of all intraarticular pathologies of intrinsic ligaments, the triangular fibrocartilage complex (TFCC), and the articular cartilage.

Table 3.6 Indications for conventional arthrography Arthrographic Technique Two-compartment arthrography (radiocarpal and midcarpal) Two-compartment arthrography (radiocarpal and distal radioulnar) Three-compartment arthrography

Indications U U

U U

U U U

Pisotriquetral

Lesion of the scapholunate and/or the lunotriquetral ligament Initial osteoarthritis/chondroarthropathy in the radio- and/or midcarpal joints Lesion of the triangular fibrocartilage (TFC) Initial osteoarthritis/chondroarthropathy in the distal radioulnar joint Combined (ligament, cartilage, TFCC) articular damage Adhesive capsulitis Loose bodies (chondromatosis)

U

Loose bodies (chondromatosis) Pain testing, pisotriquetral osteoarthritis suspected

Carpotrapezial

U

Pain testing in initial osteoarthritis of the carpometacarpal joint I

Finger joints

U

U

U

Lesions of the palmar plate and the collateral ligaments Initial osteoarthritis/chondroarthropathy

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Indications and Assessment

The weak correlation between wrist complaints and the results of arthrographic findings is due to degenerative perforations of carpal ligaments and the triangular fibrocartilage complex with increasing age. Since these lesions are often asymptomatic in middle and old age, any abnormality found in arthrographic examinations always requires careful clinical correlation. Combining arthrography with MRI or CT is always recommended to ensure that the joint cavity, as well as intra-articular soft tissues, will be directly visualized.

Further Reading Brown RR, Clarke DW, Daffner RH. Is a mixture of gadolinium and iodinated contrast material safe during MR arthrography? Am J Roentgenol. 2000;175:1087–1090. Chung KG, Zimmerman NB, Travis M. Wrist arthrography versus arthroscopy: A comparative study of 150 cases. J Hand Surg. 1996; 21A:591–594. Conway WP, Hayes CW. Three-compartment wrist arthrography: Use of low-iodine-concentration contrast agent to decrease study time. Radiology. 1989;173:569–570. Elentuck D, Palmer WE. Direct magnetic resonance arthrography. Eur Radiol. 2004;14:1956–1967. Gilula LA, Hardy DC, Totty WG, Reinus WR. Fluoroscopic identification of torn intercarpal ligaments after injection of contrast material. Am J Roentgenol. 1987;149:761–764. Gilula LA, Hardy DC, Totty WG. Distal radioulnar joint arthrography. Am J Roentgenol. 1988;150:864–866. Gilula LA, Hardy DC, Totty WG. Wrist arthrography: An updated review. J Med Imag. 1988;2:252–266. Grainger AJ, Elliott JM, Campbell RS, Tirman PF, Steinbach LS, Genant HK. Direct MR arthrography: a review of current use. Clin Radiol. 2000;55:163–176. Herbert TJ, Faithfull RG, McCann DJ, Ireland I. Bilateral arthrography of the wrist. J Hand Surg. 1990;15B:233–235. Hugo PC, Newberg AH, Newman JS, Welzner SM. Complications of arthrography. Sem Musculoskelet Radiology. 1998;209:345–348. Kessler I, Silberman Z. An experimental study of the radiocarpal joint by arthrography. Surg Gynecol Obstet. 1961;112:33–40. Kirschenbaum D, Sieler S, Solonick D, Loeb DM, Cody RP. Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg. 1995;79A: 1207–1209. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: Value of the three-compartment injection method. Radiology. 1991;179: 231–239. Linscheid RL. Arthrography of the metacarpophalangeal joint. Clin Orthop. 1974;103:91. Manaster BJ. Digital wrist arthrography: Precision in determining the site of radiocarpal-midcarpal communication. Am J Roentgenol. 1986;147:563–566. Manaster BJ, Mann RJ, Rubenstein S. Wrist pain: Correlation of clinical and plain film findings with arthrographic results. J Hand Surg. 1989;14A:466–473. Manaster BJ. The clinical efficacy of triple-injection wrist arthrography. Radiology. 1991;178:267–270.

Metz VM, Mann FA, Gilula LA. Three compartment wrist arthrography: Correlation of pain site with location of uni- or bidirectional communications. Am J Roentgenol. 1993;160 :819–822. Metz VM, Mann FA, Gilula LA. Lack of correlation of wrist pain with noncommunicating defects of the interosseous ligaments, triangular fibrocartilage, and joint capsules demonstrated by threecompartment wrist arthrography. Am J Roentgenol. 1993;160: 1239–1243. Mikic Z. Age related changes in the triangular fibrocartilage of the wrist. J Anat. 1978;126:367–384. Mikic Z. Arthrography of the wrist joint. An experimental study. J Bone Joint Surg. 1984;66A:371–378. Pessis E, Drapé JL, Bach F, Feydy A, Guerini H, Chevrot A. Direct arthrography of the pisotriquetral joint. Am J Roentgenol. 2006; 186:800–804. Quinn SF, Belsole RS, Greene TL, Rayhack JM. Work in progress: Postarthrography computed tomography of the wrist: Evaluation of the triangular fibrocartilage complex. Skeletal Radiol. 1989;17: 565–569. Quinn SF, Pittman CC, Belsole R, Greene T, Rayhack J. Digital subtraction wrist arthrography: Evaluation of the multiple-compartment technique. Am J Roentgenol. 1988;151:1173–1174. Reinus WR, Hardy DC, Totty WG, Gilula LA. Arthrographic evaluation of the carpal triangular fibrocartilage complex. J Hand Surg. 1987; 12A:495–503. Resnick D, Danzig LA. Arthrographic evaluation of injuries of the first metacarpophalangeal joint: Gamekeeper’s thumb. Am J Roentgenol. 1976;126:1046–1052. Resnick D, Andre M, Kerr R, Pineda C, Guerra Jr J, Atkinson D. Digital arthrography of the wrist: A radiographic-pathological investigation. Am J Roentgenol. 1984;142:1187–1190. Schmid MR, Schertler T, Pfirrmann CW et al. Interosseous ligament tears of the wrist: Comparison of multi-detector row CT arthrography and MR imaging. Radiology. 2005;237:1008–1013. Shigematsu S, Abe M, Onomura T, Kinoshita M, Inoue T. Arthrography of the normal and posttraumatic wrist. J Hand Surg. 1989;14A: 410–412. Schulte-Altedorneburg G, Gebhard M, Wohlgemuth WA et al. MR arthrography: Pharmacology, efficacy and safety in clinical trials. Skeletal Radiol. 2003;32:1–12. Theumann NH, Pfirrmann CW, Chung CB, Antonio GE, Trudell DJ, Resnick D. Pisotriquetral joint: Assessment with MR imaging and MR arthrography. Radiology. 2002;222:763–770. Tirman RM, Weber ER, Snyder LL, Koonce TW. Midcarpal wrist arthrography for detection of tears of the scapholunate and lunatotriquetral ligaments. Am J Roentgenol. 1985;144:107–108. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg. 1996;78A:348–356. Wilson AJ, Gilula LA, Mann FA. Unidirectional joint communications in wrist arthrography: An evaluation of 250 cases. Am J Roentgenol. 1991;157:105–109. Yin YM, Evanoff B, Gilula LA, Pilgram TK. Evaluation of selective wrist arthrography of contralateral asymptomatic wrists for symmetric ligamentous defects. Am J Roentgenol. 1996;166:1067–1073. Zanetti M, Bream J, Hodler J. Triangular fibrocartilage and intercarpal ligaments of the wrist: Does MR arthrography improve standard MRI? J Magn Reson Imaging. 1997;7:590–594. Zinberg EM, Palmer AK, Coren AB, Levinsohn EM. The triple-injection wrist arthrogram. J Hand Surg. 1988;13A:803–809.

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4

Arthroscopy H. Krimmer, P. Hahn

Arthroscopy is an invasive examination technique providing a direct view into the radiocarpal, the midcarpal, and the distal radioulnar joint. With arthroscopy, the condition of the articular cartilage, the liga-

Whereas arthroscopy quickly became established for the large joints, endoscopy of the small joints was first made possible by the development of smaller instruments that opened up new diagnostic and therapeutic perspectives in arthroscopy. Better knowledge of the complex anat-

ments, and the synovial structures can be assessed. In addition to evaluation of joint abnormalities, therapeutic interventions can be carried out in the same arthroscopy session.

omy of the wrist and increasing experience in the technical performance of arthroscopy helped to move arthroscopy out of the experimental stage into common use in hand surgery. Today it is indispensable in the treatment of wrist problems.

Necessary Equipment U

Because very little space is available for the arthroscope in those parts of the joint that are of arthroscopic interest, it is necessary to distend the joint cavity. For this purpose, with the arm bent at a right angle, a fixation device is attached to the hand, just as in the repositioning of a distal radius fracture (Fig. 4.1). Fastening a weight to the upper arm creates tension in the opposite direction, which widens the joint space. Alternatively, a traction tower can be used, in which the

U

U

U

Fig. 4.1 Therapeutic arthroscopy of the wrist. While the hand is fixed in an extension device, the arthroscopic lens is introduced through the 3–4 access. The forceps is in the 4–5 or alternatively in the 6-R portal.

arm is placed at the proximal and distal ends and stretched and can easily be moved for open interventions. The horizontal extension permits a quick exchange between arthroscopic and surgical procedures and is especially suited for arthroscopically controlled repositioning of intra-articular radius fractures. For arthroscopy of the wrist, lenses with a shank diameter between 1.7 and 2.7 mm and with an inclination of 30° at the tip of the instrument are preferable. Introduction is achieved by means of a hollow cannula with a maximal outside diameter of 3.5 mm. There is an intermediate space between the inner and the outer shank to allow fluid or gas to be introduced while the lens is in place. For purely diagnostic arthroscopy, the use of carbon dioxide as a contrast medium has the advantage of a more intensive contrast and correspondingly higher-quality images. For therapeutic interventions, however, fluid must be used to flush the joint. The arthroscope is attached to video equipment, which consists of a mounted camera, a control unit, a light source, and a monitor. Examining hooks (“probes”) of different lengths are also necessary for diagnostic purposes. For therapeutic interventions, special biopsy and gripping forceps, as well as motorized shaver systems with different heads, are used. Results are preferably recorded digitally. Connecting a personal computer with an integrated video card makes it possible to take digital freeze-frames and video sequences directly via the

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Arthroscopic Access

camera controls. Archiving is performed on CD-ROM or over a network card in the electronic patient record.

Unlike a video printout, the arthroscopic images are always available and are of higher quality.

Arthroscopic Access When planning arthroscopic access, the exact anatomical conditions of the wrist with its numerous tendons, nerves, and blood vessels must be taken into consideration. All accesses to the radiocarpal joint are on the dorsal side between the individual compartments of the extensor tendons. The accesses are named according to their continuous numbers. The distal radioulnar joint is only rarely examined arthroscopically. The standard accesses are listed in Table 4.1 and Figure 4.2. The 3–4 port is most often used to introduce the diagnostic lens, while the 4–5 port or the 6-R port serves as access for therapeutic instruments such as forceps or the shaver. A superficial slit incision is made over the planned access point, which is then bluntly widened into a working canal. The next step is puncture with a hollow cannula and trocar, which is removed after correct placement and replaced with the arthroscope. The joint is filled with fluid or carbon dioxide through the introducer lock.

radial artery MCU MCR

6-U

3–4

6-R 4–5 dorsal branch of the ulnar nerve

superficial branch of the radial artery

extensor carpi ulnaris

Fig. 4.2 Arthroscopic accesses. The accesses to the radiocarpal joint on the extensor side (3–4, 4–5, 6-R, and 6-U) and the accesses to the midcarpal joint (MCR and MCU) are marked in red.

Table 4.1 Accesses for arthroscopy of the wrist Joint

Port

Access

Radiocarpal joint

3–4

Between the tendons of the extensor pollicis longus and the extensor digitorum communis

4–5

Between the tendons of the extensor digitorum communis and the extensor digiti minimi

6-R

Radial to the extensor carpi ulnaris tendon

6-U

Ulnar to the extensor carpi ulnaris tendon

MCR

Radial to the head of the capitate (midcarpal radial)

MCU

Ulnar to the head of the capitate (midcarpal ulnar)

Midcarpal joint

Distal radioulnar joint

In the proximal joint recess

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Normal Arthroscopic Findings Diagnostic arthroscopy is performed according to a standard procedure. U

The Radiocarpal Joint (Fig. 4.3) U

U

U

a

After the arthroscope is introduced through the 3–4 port, the ligaments on the flexor side come into view. After careful retraction of the instrument, the condition of the articular cartilage is assessed, and the scaphoid and the corresponding joint surface of the radius up to the radial styloid process are examined. The arthroscope is then directed toward the ulna to assess the palmar ligaments, which are covered by a thin synovial membrane (Fig. 4.4 a). On the radial side, the radioscaphocapitate ligament is seen; on the ulnar side, the radiolunotriquetral ligament is seen. Only the proximal sections of these ligaments can be visualized. The vascularized radioscapholunate (RSL) ligament runs at right angles to the radial joint surface. To assess the presence of a ruptured or loose ligament, a probe should be introduced through a special working canal, generally the 3–4 port. If the arthroscope is further retracted, a small rim is seen, which is the transition between the scaphoid and the lunate, across which the scapholunate ligament stretches (Fig. 4.4 b). This is also where the probe

is used to recognize a damaged scapholunate ligament. The cartilaginous proximal surface of the lunate and the fossa lunata of the radius can be assessed further toward the ulnar side. The transition between the lunate and triquetrum is usually smooth and covered with cartilage, making it possible to differentiate between the two bones with the probe.

scapholunate ligament radioscaphocapitate ligament radiolunotriquetral ligament RSL ligament fossa scaphoidea

lunotriquetral ligament ulnotriquetral ligament prestyloid recess (arrow) ulnolunate ligament triangular fibrocartilage complex (TFCC) fossa lunata

Fig. 4.3 Diagram of the arthroscopic anatomy of the radiocarpal joint.

b

Fig. 4.4 a–c Normal arthroscopic findings in the radiocarpal joint. a Radioscapholunate (RSL) ligament. b Scapholunate (SL) ligament. c Test of the triangular fibrocartilage complex (TFCC) with the examining probe. In the upper part of the picture, one sees the lower surface of the triquetral cartilage. c

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Indications for Diagnostic Arthroscopy

U

On the flexor side, the ulnolunate and ulnotriquetral ligaments come into view. Slightly retracting the arthroscope permits a view of the triangular fibrocartilage complex (TFCC), which has a stretched tentlike shape with a smooth surface. The TFCC is the continuation of the joint surface of the radius with the styloid process of the ulna. The ulnar recess can be found adjacent to the styloid process on the palmar side. The probe must be introduced to detect peripheral avulsions of the TFCC, which normally has a trampoline-like effect when probed (Fig. 4.4 c). Absence of a trampoline-like reaction indicates a peripheral tear in the TFCC.

U

U

The distal cartilaginous surface of the scaphoid, the lunate, and triquetrum can be assessed, as can the scapholunate and lunotriquetral ligamentary transition. If damage to a ligament is suspected, its stability can be tested with the probe. Distal from this point, it is important to inspect the head of the capitate for cartilaginous damage. On the radial side the scaphotrapeziotrapezoid joint with the distal pole of the scaphoid and the bases of the trapezium and trapezoid can be seen and, on the ulnar side, the lower cartilaginous surface of the hamate comes into view.

The Distal Radioulnar Joint

The Midcarpal Joint U U

The arthroscope is brought into position via the MCR port and, if necessary, a probe is introduced via the MCU port, as described above.

The proximal side of the triangular fibrocartilage complex and the distal joint surface of the ulnar head can be assessed with this rarely seldom-needed arthroscopic examination.

Indications for Diagnostic Arthroscopy Indications for arthroscopy of the wrist essentially concern two different patient groups. U In the first group, the extent of the damage in already confirmed pathologic findings is of interest. For example, assessment of the degree of osteoarthritis resulting from an intra-articular radius fracture, carpal collapse, or osteonecrosis of the lunate is important before deciding on further therapeutic measures. U In the second group, arthroscopy as a definitive diagnostic procedure is indicated if complaints in the wrist cannot be linked to a certain disease entity, even after the usual clinical and technical examinations have been carried out. Figure 4.5 shows arthroscopic diagnosis of a ruptured scapholunate ligament.

Fig. 4.5 Complete rupture of the scapholunate ligament. Radiocarpal arthroscopy with a midcarpal view of the head of the capitate.

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Fig. 4.6 a, b Arthroscopic findings in lesions of the triangular fibrocartilage (TFC).

a Central tear of the triangular fibrocartilage. A probe has been introduced.

b Degenerative perforation of the triangular fibrocartilage.

Indications for Therapeutic Arthroscopy Arthroscopic surgery of the wrist is currently carried out for the disease entities listed in Table 4.2. Main attention is directed to injuries of the triangular fibrocartilage complex. The kind of arthroscopic treatment depends on the differently vascularized zones of the TFCC. U Traumatic tears (Palmer’s Class I) in the central, avascular area are treated by debridement with a special shaver system and forceps (Fig. 4.6 a). Ruptures in the vascular marginal areas, which are decisive for stability, can be sutured under arthroscopic control with the aid of two cannulas through which the suture material is introduced.

U

Degenerative changes (Palmer’s Class II) can be found in the avascular area in the center of the TFCC and should therefore also first be treated by arthroscopic debridement (Fig. 4.6 b). The therapeutic success is about 70 %. If debridement brings no relief, shortening osteotomy of the ulna can be performed.

Reduction of intra-articular fractures of the radius, which are impossible or difficult to assess with fluoroscopic guidance, can be undertaken under arthroscopic control. This approach is especially effective for fractures with central compression of the radiocarpal joint surface.

Contraindications and Complications Localized or generalized infections, as well as sympathetic reflex dystrophy, always constitute contraindications. Attention must also be called to the possibility of iatrogenic damage to the articular cartilage during the relatively difficult puncture of the wrist. The superficial branch of the radial nerve or the dorsal branch of the ulnar nerve can be damaged by careless examination technique. Air or fluid that has entered soft tissue is gen-

Table 4.2 Indications for arthroscopic surgery of the hand U U U

U U

Removal of cartilaginous loose bodies Synovectomy Injuries of the triangular fibrocartilage complex: – Traumatic tears – Degenerative changes Repositioning of intracarpal malalignments Reduction of intra-articular radius fractures

erally quickly and completely absorbed. The rate of complications is reported to be less than 2 %.

Further Reading Adolfsson L, Povlsen B. Arthroscopic findings in wrists with severe post-traumatic pain despite normal standard radiographs. J Hand Surg. 2004;29B:208–213. Atik TL, Baratz ME. The role of arthroscopy in wrist arthritis. Hand Clin. 1999;15:489–494. Beyermann K, Krimmer H, Lanz U. TFCC (Triangular Fibrocartilage Complex) lesions. Diagnosis and therapy. Orthopäde. 1999;28: 891–898. Botte MJ, Cooney WP, Linscheid RL. Arthroscopy of the wrist: Anatomy and technique. J Hand Surg. 1989;14A:313–316. Chung KG, Zimmerman NB, Travis M. Wrist arthrography versus arthroscopy: A comparative study of 150 cases. J Hand Surg. 1996; 21A:591–594. Cooney WP, Dobyns JH, Linscheid RL. Arthroscopy of the wrist: Anatomy and classification of carpal instability. Arthroscopy. 1990;6: 133–140. Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy. J Hand Surg. 1994;18A:815–822.

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Contraindications and Complications

Cooney WP. Arthroscopic anatomy of the wrist. In: Cooney WP, Linscheid RL, Dobyns JH. The Wrist. Diagnosis and Operative Treatment. Vol 1. St. Louis, Mo: Mosby; 1998:169–187. Culp RW. Complications of wrist arthroscopy. Hand Clin. 1999;15: 529–535. Ekman EF, Poehling GG. Principles of arthroscopy and wrist arthroscopy equipment. Hand Clin. 1994;10:557–566. Hempfling H. Die Arthroskopie am Handgelenk. Indikation, Technik und therapeutische Konsequenzen. Stuttgart: Wiss. Verlagsgesellschaft mbH; 1992. Geissler WB, Freeland AE. Arthroscopic management of intraarticular distal radius fracture. Hand Clin. 1999;15:455–465. Gelberman RH, ed. The Wrist. New York, NY: Raven Press; 1994. Nagle DJ. Arthroscopic treatment of degenerative tears of the triangular fibrocartilage. Hand Clin. 1994;10:615–624. North ER, Thomas S. An anatomic guide for arthroscopic visualization of the wrist capsular ligaments. J Hand Surg. 1988;13A:815–822. Osterman AL. Basic wrist arthroscopy and endoscopy. Hand Clin. 1994;10:4–12.

Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg. 1989;14A:594–606. Poehling GG, Siegel DB, Koman AL, Chabon SJ. Arthroscopy of the wrist and elbow. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol 1. New York, NY: Churchill Livingstone; 1993:189–214. Stanley J, Saffar P. Wrist Arthroscopy. London: Martin Dunitz; 1994. Viegas SF. Midcarpal arthroscopy: anatomy and portals. Hand Clin. 1994;10:577–587. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg. 1996;78A:348–356. Whipple TL, Marotta J, Powell J. Techniques of wrist arthroscopy. Arthroscopy. 1986;2:244–252. Whipple TL. Arthroscopic surgery. In: Whipple TH, ed. The Wrist. Philadelphia, Pa: Lippincott; 1992:73–90. Whipple TL, Dwyer TA. Wrist arthroscopy. In: Watson HK, Weinzweig J, eds. The Wrist. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:83–94.

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Arteriography T. Helmberger, R. Schmitt

A number of vascular variants are found in the forearm and hand, especially constitutional differences in the palmar arch resulting from a dominant radial or ulnar arterial supply. Indications for imaging of arteries in the forearm and hand are circulatory disturbances, inflammatory vascular diseases such as obliterating thrombangitis and traumatic vascular lesions, and the presurgical evaluation of congenital anomalies of the hand and vascularized soft-tissue tumors (especially hemangiomas). Catheter angiography with transfemoral or transbrachial access

needle angiography is an invasive procedure. Advantages of these methods are the high spatial resolution with demonstration of even the smallest vessels, as well as functional recording of the blood flow. Contrast-enhanced magnetic resonance (MR) angiography differentiates between high-resolution and temporal-resolution techniques. Three-dimensional data sets can provide multiplanar maximal-intensityprojection (MIP) angiograms, whereas temporal-resolution data sets can only provide MIP images in the acquisition plane.

ARI

Anatomy and Variants of Hand Arteries

ADC

APS

Forearm Arteries

APPO

The ulnar artery originates directly from the brachial artery. In the forearm, the arteria interossea communis, whose dorsal branch provides part of the arterial circulation of the back of the hand, branches off from it. In rare cases, there is a persisting median artery, which can join the superficial palmar arch. The ulnar artery divides into a superficial and a deep palmar arch in Guyon’s canal. The radial artery originates in 80–85 % of the cases from the brachial artery in the elbow. In the remaining 15–20 %, it branches off high up from the brachial artery or the axillary artery, which can cause misinterpretation when the brachial artery is punctured. In the periphery, the radial artery passes dorsally and crosses the trapezium and the base of the first metacarpal. In 96 % of the cases, it runs along the palmar side of the hand in interdigital space I–rarely in II–or, after dividing into an accessory vessel, in interdigital spaces I and II. Next to the junction with the superficial and deep palmar arches, the main branches of the princeps pollicis artery and the radialis indicis artery, as well as the dorsal carpal network (to the rete carpi dorsalis) branch off from the radial artery in the periphery.

APP RPAU RSAR

AU AR

Fig. 5.1 Diagram of the arterial palmar arch. Filling of the superficial palmar arch by the ulnar artery. Communication with the radial artery over the superficial branch of the radial artery. The deep palmar arch is filled by the radial artery. Anastomosis with the ulnar artery via the deep branch of the ulnar artery. Abbreviations: ADC = aa. digitales communes; APPO = a. princeps pollicis; APP = arcus palmaris profundus; APS = arcus palmaris superficialis; AR = a. radialis; ARI = a. radialis indicis; AU = a. ulnaris; RPAU = rete profundus a. ulnaris; RSAR = rete superficialis a. radialis.

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Anatomy and Variants of Hand Arteries

Arteries in the Palm The palmar arteries represent a complex system of collaterals, which consists mainly of two palmar arches (Fig. 5.1). U The superficial palmar arch is mainly fed by the ulnar artery. After passing through Guyon’s canal, the ulnar artery joins the superficial palmar arch, which ends superficially in relation to the flexor tendons of the fingers and the branches of the median nerve in the middle of the palm. The superficial palmar arch is closed in 42 % of cases and anastomoses via its superficial radial branch with the radial artery. In 58 % of cases, the arch is congenitally open. On the radial side of the hand, the common digital arteries originate from the superficial palmar arch, which projects onto the middle of the metacarpals in angiograms. U The deep palmar arch is fed primarily by the radial artery in 97 % of the cases. Before reaching the deep

palmar arch, however, the radial artery takes a dorsal detour by leaving the flexor side of the forearm at the level of the anatomical snuff box, and, after passing a short distance through metacarpal space I/II, returns to the palmar side. The deep palmar arch lies on top of the interosseous muscles and between the two heads of the adductor pollicis muscle deep in the middle of the palmar compartment. In 95 % of cases, it is congenitally closed by an anastomosis with the deep network of the ulnar artery. In angiography, the deep palmar arch projects on the bases of the metacarpals, running proximal to the superficial arch. The princeps pollicis artery, radial indicis artery, and smaller palmar metacarpal arteries originate from the deep palmar arch. Table 5.1 and Figure 5.2 summarize the arterial variants in the hand. Figures 5.3 and 5.4 show examples of the arterial variations as depicted in angiograms.

Table 5.1 Variations in the arterial palmar arch (according to Lippert and Pabst) Superficial palmar arch with closed arc Radioulnar

Normal textbook case

35 %

Fig. 5.2 a

Medianoulnar

Persisting median artery

4%

Fig. 5.2 b

Radiomedianoulnar

Persisting median artery

1%

Fig. 5.2 c

Profundoulnar

Anastomosis with the deep palmar arch

2%

Fig. 5.2 d

Superficial palmar arch with open arc Ulnar

All common palmar digital arteries from the ulnar artery

37 %

Fig. 5.2 e

Ulnoradial

Common palmar digital artery I originates from the radial artery, the rest from the ulnar artery

31 %

Fig. 5.2 f

Radioulnar

Common palmar digital arteries I and II originate from the radial artery, III and IV from the ulnar artery

3%

Fig. 5.2 g

Radiomedianoulnar

Common palmar digital artery II originates from the median artery

1%

Fig. 5.2 h

Medianoulnar

Common palmar digital arteries I and II originate from the median artery, III and IV from the ulnar artery

4%

Fig. 5.2 i

79 %

Fig. 5.2 j

13 %

Fig. 5.2 k

5%

Fig. 5.2 l

3%

Fig. 5.2 m

Deep palmar arch Radioulnar Radioulnar

Two deep ulnar branches

Radiomedianoulnar

Median artery also involved

Open arc

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5 Arteriography

a

b

c

d

e

f

g

h

j

k

l

m

n

o

p

q

Fig. 5.2 a–q The most common variants of the hand and finger arteries (modified according to Lippert and Pabst). a–d Variants with closed superficial palmar arch. e–i Variants with open superficial palmar arch. j–m Variants of the deep palmar arch.

i

n–q Variants of the common and proper palmar digital arteries. Anatomical courses of vascular variants are described in more detail in Tables 5.1 and 5.2.

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Anatomy and Variants of Hand Arteries

p

c

;

;

;

m

Fig. 5.4 Intra-arterial DSA of a persistent median artery. Medianoulnar vascular supply of the hand combined with a persistent median artery (arrows). The radial artery is not present, and the deep palmar arch is hypoplastic.

Fig. 5.3 Variants with aplasia of the deep palmar arch. The deep palmar arch is not visualized in arterial DSA. A normal superficial palmar arch is seen (arrow), as well as the metacarpal palmar arteries (m) and the common (c) and proper (p) palmar digital arteries.

Arteries of the Finger In accordance with the wealth of variations in the palmar arch, the palmar metacarpal arteries, the common palmar digital arteries, and the proper digital arteries can have different sources of vascular supply (Fig. 5.5). The most common vascular variants are summarized in Table 5.2.

Fig. 5.5 Normal DSA findings of the common and proper palmar digital arteries.

Table 5.2 Variations in the arteries (Aa.) of the fingers (according to Lippert and Pabst) Aa. digitales palmares communes Arteries of the thumb

Originate from the superficial palmar arch U U

Arteries of the thumb and index finger Communications between Aa. digitales palmares communes and Aa. metacarpae palmares

Originate from both palmar arches Originate entirely from the deep palmar arch as the main artery of the thumb

Originate from the deep palmar arch U U

No communications Communicates via the proper palmar digital arteries

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77 %

Fig. 5.2 n

10 % 11 %

Fig. 5.2 o

2%

Fig. 5.2 q

60 % 30 %

Fig. 5.2 p

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5 Arteriography

Arteries of the Dorsum of the Hand

tem of the palm, it is more delicate and, therefore, only of secondary importance for the arterial supply of the hand.

The vascular network on the dorsum of the hand does not supply the fingers. In comparison to the vascular sys-

Diagnostic Imaging Contrast Agents and Their Application

Catheter Angiography Prerequisites For invasive transarterial angiography, the following prerequisites must be fulfilled: U The primary physician and the radiologist must agree on the indication. U The examiner must inform the patient about the examination at least 24 hours in advance. The information must include the reason for the examination and the procedure, possible risks of puncture, catheter manipulation, and administration of contrast medium. The patient or his or her legal representative must provide informed consent with a signature (an exception is emergency investigation with vital indication). U A medical history must be taken regarding cardiovascular risk factors, bleeding tendency, previous vascular surgery, thyroid diseases, and current medication. U A current laboratory status must be available, including: PTT (< 40 s), Quick’s value (> 50 %), INR (< 1,4), thrombocytes (> 60 000/µl), and serum creatinine (< 1.6 mg/dl).

Arterial Accesses The brachial artery through direct puncture in the elbow (needle angiography) or the common femoral artery (catheter angiography) provide suitable accesses for arteriography of the arm and hand. The choice of procedure depends on the clinical objective and the condition of the blood vessels. The brachial artery is punctured on the ulnar side up to a maximum of 1.5 cm proximal of the elbow. Sometimes vascular spasm occurs at the puncture site. Arterial puncture is performed according to Seldinger’s technique. When the angiographic examination is complete, local pressure is applied to the puncture site for about 10 minutes, and a compression dressing is applied.

Puncture and Catheter Materials To minimize vascular trauma, the smallest diagnostically sufficient cannulas and catheter calibers are to be chosen. Refer to the recommendations in Table 5.3.

Today only nonionic contrast agents are recommended because they are better tolerated (Table 5.4). Because of their molecular structure, the nonionic contrast agents are hypo-osmotic to iso-osmotic and are hydrophilic. They cause less pain during injection, especially if a dimeric contrast medium from this group is administered. Contrast medium (5–10 ml) is administered manually through a selective catheter inserted into the femoral artery or an indwelling cannula in the brachial artery. In digital subtraction angiography (DSA), the contrast medium can be diluted with a saline solution. Thromboses in the lumen or on the tip of the catheter are avoided by flushing the catheter with a heparin–saline solution. When the catheter is placed beyond the brachiocephalic trunk or the subclavian artery, intraTable 5.3 Material used in arteriography of adult hands With a femoral access 18-gauge puncture cannula U 0.035 or 0.032-inch guide wire (PTFE or Terumo) U Introducer sheath of the same size U F4 (or F5) selective catheter U

With a brachial access (needle angiography) 21-gauge puncture cannula U Short 0.028-inch guide wire U Extension tube U

Table 5.4 Nonionic contrast medium used in arteriography Generic Name

Commercial Name

Concentration (mg/ml)

Iodixanol

Visipaque

150–270–320

Iomeprol

Imeron

150–250–300–350–400

Iopromid

Ultravist

150–240–300–370

Iohexol

Omnipaque Accupaque

240–300–350 240–300–350

Ioversol

Optiray

160–240–300–320–350

Iopentol

Imagopaque

150–200–250–300–350

Iobitridol

Xenetix

250–300–350

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Diagnostic Imaging

arterial administration of 2500 IU (international units) of heparin is recommended. If the patient is known to have anaphylactic reactions to contrast medium, hyperthyroid metabolism, or compensated renal insufficiency, contrast-enhanced MR angiography is the best alternative. With obvious limitations and caution, angiography with carbon dioxide as a contrast agent may be used.

available for electronic postprocessing (e.g., mask shifting, changes in contrast/brightness and contours). The advantage of improved density resolution, the lack of overlapping of bony structures, the instantaneous availability of the digital image, and the various possibilities for postprocessing with DSA considerably outweight that of the higher spatial resolution of the conventional film–screen technique.

Pharmacoangiography

Examination Risks

For the functional diagnosis of primary Raynaud syndromes, image comparisons before and after intra-arterial application of a vasodilative ¥-sympatholytic substance is essential. Such vasodilative substances (e.g., acetylcholine chloride or glycerol trinitrate) are slowly injected into the artery over a period of one minute. Contraindications are tachyarrhythmic cardiac diseases. The vasodilative effect lasts for a few minutes.

Complications associated with catheter angiography correlate largely with the experience of examiners and are reported to occur at a rate of 1.7–7 %. The rate of allergic reactions with nonionic contrast agents is less than 1.5 %. Table 5.5 lists all known complications.

Phlebography Since a complete representation of the veins in the hand with direct phlebography is technically challenging, the veins, most of which are on the dorsum of the hand, can best be viewed indirectly in the venous drainage phase of arteriography.

Image Acquisition in Digital Subtraction Angiography Digital subtraction angiography (DSA) is the angiographic imaging procedure of choice. The digital imaging process occurs with a matrix usually containing 1024 × 1024 pixels and an image depth of 256–1056 shades of gray. In subtraction procedures, the contrastfilling image is electronically subtracted from the precontrast image (mask), leaving only the image of the contrast-filled vessels. The digitally stored images are

MR Angiography Contrast-enhanced MR angiography with the acquisition of fast three-dimensional (3D) data sets has made enormous progress in the last few years and has already taken over some indications in the evaluation of arteries in the forearm and hand.

Perequisites The contraindications for MR tomography explained in Chapter 9 (e.g., cardiac pacemaker, ferromagnetic implants and foreign bodies, allergies to contrast medium) must be considered and excluded during the explanation to the patient and written informed consent procedure preceding the examination. In the “small parts” of the hand, MR angiography should only be performed on a high-field scanner with 1.5 T field strength, with significant limitations on 1.0 T if necessary. Examination using a surface coil is obligatory, and multichannel phased-array coils are preferable.

Table 5.5 Risks in catheter angiography, prophylaxis, and treatment Risks Associated with Catheter

Risks Associated with Contrast Agent

At puncture site

Allergic

U U U U U

Local hematoma Vascular occlusion Pseudoaneurysm Arteriovenous fistula Nerve damage, even chronic causalgia

In target region U

U

U

Vascular dissection from subintimal catheter introduction Peripheral embolism Vascular occlusion

U U U U U

U

U

Largely independent of dose Reactions < 1.5 % Sneezing, itch, restlessness Vomiting, urticaria, hypotension Bronchospasm, Quincke’s edema, circulatory failure Premedication: oral corticosteroids for 2 days Emergency therapy: corticosteroids, antihistamines, and H2-blockers

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Nephrotoxic U

U

U

U

Correlates with amount of contrast medium From 250 ml often temporary disturbance of renal function Previously in compensated renal insufficiency, diabetes mellitus, hyperuricemia, multiple myeloma, and dehydration Pre- and post-angiographic hyperhydration lessens risk of kidney damage

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Type of Sequence, Sequence Parameters Contrast-enhanced MR angiography is preferred for diagnostic imaging of peripheral arteries because of its good contrast resolution compared to the plain time-of-flight (TOF) technique and because it is considerably less prone to artifacts than the phase-contrast (PC) technique. Because of high demands on spatial resolution, 3D gradient-echo sequences (Turbo-FLASH, FSPGR, TFE) are best suited. Nearly isotropic voxel sizes of 0 .1 mm3 can be achieved by using dedicated surface coils. This requires limiting the field of view (FoV) to the anatomical region of interest and using an acquisition matrix of at least 256 in the frequency-encoding direction. Because of the short repetition time (TR) used, the signal from nonvascular soft-tissue structures is weak that the subtraction technique in three-dimensional, gradient-recalledecho (GRE) MR angiography may be unnecessary in some cases. Two techniques with different requirements for spatial and temporal resolution are employed: U Time-resolved MR angiography provides a dynamic series of angiographic images (Fig. 5.6). The necessary shortening of the scan time is achieved by exciting and reading out only a few coronally oriented partition slices with a slice thickness of 8 mm per phase. The re-

U

sulting scan time is 3–5 seconds per phase. Ten phases are measured without bolus timing. Only vascular images in the acquired coronal plane can be calculated in maximal-intensity-projection (MIP) postprocessing, but not multiplanar images. Another disadvantage is the partial-volume effect, which decreases the quality of images of the small finger arteries. In high-resolution MR angiography, the attempt is made to achieve a dataset with nearly isotropic resolution by using thin partition slices (Fig. 5.7). Multiplanar projections of vessels can be computed with the MIP reconstruction method from the volumetric dataset. Typical acquisition parameters of high-resolution MR angiography are a partition-slice thickness of 1 mm and a scan time of about 25 seconds. An advantage of the high-resolution technique is the possibility of visualizing the arteries of the fingers; disadvantages include the necessity of exact bolus timing and contamination with overlapping veins when using a sequence with linear or centric k-space filling.

Contrast Medium and Its Application Gadolinium chelates are suitable as contrast agents for MR angiography (see Table 9.4). Because of the small diameter of the blood vessels of the hand, two to three times the dose of contrast medium is recommended, i.e., Fig. 5.7 High-resolution technique of enhanced MR angiography of the arteries of the hand and fingers. Normal findings in the early arterial phase in a 12-year-old boy. The distal sections of the fingers are in the margins of the coil field.

a

b Fig. 5. 6 a, b Time-resolved technique of enhanced MR angiography of the forearm arteries. Normal findings in a 39-year-old man. a The coronal MIP 18 seconds after the beginning of the injection corresponds to the early arterial phase. b Late arterial filling 24 seconds after the beginning of the injection.

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Diagnostic Imaging

Table 5.6 Scan parameters for enhanced MR angiography of the hand (three-dimensional GRE sequence, 1.5 T magnet, dedicated surface coil) Parameter

High-resolution Technique

Time-resolved Technique

Sequence

3D GRE (turbo-FLASH, FSPGR, TFE)

3D GRE (turbo-FLASH, FSPGR, TFE)

TR

3–7 msec

3–7 msec

TE

1–3 msec

1–3 msec

Flip angle

25°

25°

Slab thickness

40 mm

40 mm

Number of partitions

40

5

Effective slice thickness

1 mm

8 mm

Acquisition matrix

512 × 176

512 × 176

Rectangular FoV

50 %

50 %

FoV

25 cm

25 cm

Band width

Maximal

Maximal

Acquisitions/phase

1

1

Phases

1

10

Scan time/phase

25–30 sec

3–5 sec

Scan delay

Depends on test bolus

Approximately 15 s

Maximal intensity projection

Multiplanar

Only coronal

0.2 – 0.3 mmol/kg body weight. For orientation use 20 ml and a flow of 2.5–3 ml/sec for a contrast agent of medium relaxivity (like Magnavist) and use 12 ml and a flow of 2 ml/s for a contrast medium of high relaxivity (like MultiHance). The contrast agent is injected under standardized conditions with a double-head injector. The contrast medium is administered first and followed directly by a bolus of physiological saline solution, which keeps the bolus density compact.

Arrival of the Contrast Medium For exact synchronization (to the second) of the administration of contrast agent with the instant of highest contrast intensity, the following parameters must be known during data acquisition: U The time interval from the beginning of the injection to the arrival of the contrast medium in the target area (contrast travel time) U The length of time taken to inject the bolus of contrast medium (bolus length) U The acquisition time of the sequence per phase U The measuring order for readout of the k-space (linear, centric, elliptic-centric, etc.).

U

U

with a time-resolved, single-slice sequence with 1 image/sec; the contrast travel time is determined; and the start delay is calculated with the aid of a formula. An alternative to the test bolus is automatic bolus pursuit. The scan sequence is started when a signal threshold is reached as a result of the arrival of the contrast medium in the target area (for example, the Smart-Prep procedure). When the bolus is followed visually, the examiner observes the arrival of the contrast agent during a timeresolved fluoroscopic sequence and starts the scanning process manually (for example, the Care Bolus procedure).

Maximal Intensity Projection The angiographic images are computed by reconstruction of the maximal intensity projection from the 3D image dataset. In time-resolved MR angiographies, the MIP reconstructions are carried out only in the coronal acquisition plane. MIP images can be produced in any desired spatial plane in high-resolution MR angiography.

Specific Differential Indications Synchronization can be achieved in different ways: U By estimating the scan delay. For time-resolved MR angiography, a delay of 15 seconds has proved useful. U In the test-bolus procedure, the arrival of a 2 ml bolus of contrast medium in the target area is monitored

Although the technique of MR angiography has made considerable progress, digital subtraction angiography remains the diagnostic gold standard for imaging the thin arteries of the fingers. The advantage of transarterial

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Table 5.7 Recommendations for diagnostic imaging of the arteries of the hand Catheter/Needle Arteriography

MR Angiography

Emergency diagnosis U Embolism/completing thrombosis U Vascular trauma

Elective diagnosis U Presurgical for congenital anomalies of the hand U Presurgical before plastic surgery with large flaps U Presurgical for vascular tumors (like hemangiomas)

Urgent diagnosis U Dry/moist gangrene with pAVK U Ergotism suspected

Urgent diagnosis U Aneurysm of the radial or ulnar artery U Steal phenomenon after shunt placement

Functional diagnosis U Differentiation between primary and secondary Raynaud syndromes

Functional diagnosis U Thoracic-outlet syndrome

Confirming diagnosis U Thrombangitis obliterans Winiwarter–Buerger U Panarteritis nodosa

Confirming diagnosis U Hypothenar-hammer syndrome

catheter angiography lies in examinations of the vascular periphery and in the diagnosis of vascular emergencies. In Table 5.7 an attempt is made to correlate the various indications for diagnostic imaging of the arteries of the hand with digital subtraction angiography and MR angiography. These recommendations must be individually adapted to the patient’s current clinical condition and the local provisions for examination in the hospital. The angiographic findings in vascular diseases in the hand are clarified in Chapter 48.

Further Reading Arneklo-Nobin B, Albrechtsson U, Eklöf B. Indications for angiography and its optimal performance in patients with Raynaud’s phenomenon. Cardiovasc Intervent Radiol. 1985;8:174–179. Beck A. Angiographie der Hand. Heidelberg: Springer; 1994. Blackband SJ, Chakrabarti I, Gibbs P, Buckley DL, Horsman A. Threedimensional MR imaging and angiography with a local gradient coil. Radiology. 1994;190:895–899. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet. 1961;113:409–424. Connell DA, Koulouris G, Thorn DA, Potter HG. Contrast-enhanced MR angiography of the hand. Radiographics. 2002;22:583–599. Corot C, Perrin JM, Belleville J, Amiel M, Eloy R. Effect of iodinated contrast media on blood clotting. Invest Radiol. 1989;24:390–393. Erlandson EE, Forrest ME, Shields JJ et al. Discriminant arteriographic criteria in the management of forearm and hand ischemia. Surgery. 1981;90:1025–1036. Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part I: The extraosseous vascularity. J Hand Surg. 1983;8A:367–375. Goldfarb JW, Hochman MG, Kim DS, Edelman RR. Contrast-enhanced MR angiography and perfusion imaging of the hand. Am J Roentgenol. 2001;177:1177–1182. Golman K, Almén T. Contrast media-induced nephrotoxicity: Survey and present state. Invest Radiol. 1985;21:92–97. Grollman Jr JH, Marcus R. Transbrachial arteriography: Techniques and complications. Cardiovasc Intervent Radiol. 1988;11:32–35. Harder T, Lackner K, Franken T. Digital subtraction angiography (DSA) of the upper extremities. Fortschr Röntgenstr. 1983;139:609–615. Hessel SJ, Adams DF. Complications of angiography. Radiology. 1981; 138:273–281.

Janevski B. Arterial embolism of the upper extremities. Fortschr Röntgenstr. 1986;55:431–434. Kawabata H, Matsui Y, Kitano M. Magnetic resonance angiography of the forearm and hand in children. Hand Surg. 2001;6:157–162. Keller FS, Rösch J, Dotter CT, Porter JM. Proximal origin of the radial artery: potential pitfall in hand angiography. Am J Roentgenol. 1980;134:169–1970. Lee VS, Lee HM, Rofsky NM. Magnetic resonance angiography of the hand. Invest Radiol. 1998;33:687–698. Lippert H, Pabst R. Arterial Variations in Man. Classification and Frequency. Munich: Bergmann; 1985. Machleder H. Vaso-occlusive disorders of the upper extremity. Curr Probl Surg. 1988;25:7–67. Malms J. Angiographie von Kopf, Hals und oberen Extremitäten. In: Schild H, ed. Angiographie – Angiographische Interventionen. Stuttgart: Thieme; 1994:31–95. Mills JL, Friedman EI, Taylor LM, Porter JM. Upper extremity ischemia caused by small artery disease. Ann Surg. 1987;206:521–527. Moore RD, Steinberg EP, Powe NR et al. Nephrotoxicity of highosmolality versus low-osmolality contrast media: Randomized clinical trial. Radiology. 1992;182:649–655. Moran KT, Halpin DM, Zide RS, Oberfield RA, Jewell ER. Long-term brachial artery catheterization: Ischemic complications. J Vasc Surg. 1988;8:76–78. Prince M. Gadolinium-enhanced MR aortography. Radiology. 1994; 191:155–164. Rosenthal, H, Majewski A, Wagner HH. Handarteriographie. Chirurgische Indikationen und Ergebnisse. Fortschr Röntgenstr. 1987;56: 51–57. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: A new technique. Acta Radiol. 1953;39:368–376. Shehadi WH, Toniolo G. Adverse reactions to contrast media: A report from the Committee on Safety of Contrast Media of the International Society of Radiology. Radiology. 1980;137:299–302. Spindler-Thiele S, Schmitt R, Helmberger T, Pogan J, Gullotta U. Ambulant transbrachial 4-French arteriography with particular reference to the aortofemoral vascular system. Fortschr Röntgenstr. 1993;159:174–179. Vogelzang R. Arteriography of the hand and wrist. Hand Clin. 1991;7: 65–70. Wenz W, Beduhn D. Extremitätenangiographie. Heidelberg: Springer; 1976. Winterer JT, Scheffler K, Paul G et al. Optimization of contrastenhanced MR angiography of the hands with a timing bolus and elliptically reordered 3D pulse sequence. J Comput Assist Tomogr. 2000;24:903–908.

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Skeletal Scintigraphy J. Spitz

Three-phase skeletal scintigraphy (TPS) of the hand makes it possible to evaluate the regional circulation and bone metabolism in a single examination. Pathologic factors that can exert an influence are osseous hyperemia, ischemia, callus development following fracture, inflammation of the bones and joints, inac-

tivity osteoporosis, and trophic disorders. Skeletal scintigraphy is primarily employed to exclude pathologic osseous processes, to identify fractures, and to provide further differentiation when radiographic results are inconclusive. In such cases, scintigraphy often plays a decisive role.

Physical-Technical Foundations In comparison to radiologic procedures, diagnosis in nuclear medicine is more functionally oriented. It is based on the tracer method. A radioactive substance in a pharmacologically ineffective dose is administered to the metabolic system of interest. The spatial distribution of the radiopharmaceutical substance can be measured at the patient’s body surface as a result of its emission of gamma radiation. At present the most commonly used isotope is technetium-99 m (99mTc), which, depending on the clinical objective, is linked to various carrier substances. It is obtained from a molybdenum-99 generator in a technically uncomplicated process, so that it is rouTable 6.1 Examination protocol for three-phase scintigraphy Positioning of the hand: U Including the opposite side U Below or on the gamma camera Bolus injection of 99mTc-labeled diphosphonate U 7–10 MBq per kg body weight U Reduced dose for children as shown in Table 6.6 First phase: Arteriovenous circulation U 60 single images lasting 1 second each Second phase: Early-phase scintigram U One or more static scintigrams Third phase: Late-phase scintigram U 2–5 hours after injection of tracer U Various single projections

tinely available. Technetium-99 m gives off monoenergetic gamma radiation (electromagnetic radiation) with an energy of 140.5 keV. Owing to its brief half-life of 6.03 hours and lack of corpuscular radiation, this isotope has ideal characteristics with regard to radiation exposure as well as imaging quality. The current standard instrument is the digital wide-field gamma camera with an effective field of view of about 40 cm × 55 cm. Three-phase scintigraphy demonstrates arteriovenous circulation, the early distribution phase in tissue, and the late distribution of the tracer in the skeletal system. The standard examination protocol is given in Table 6.1. Evaluation and documentation of data can be carried out in different ways (Fig. 6.1). For quantification, the region-of-interest technique (ROI technique) is generally used. Although the ROI areas should be generously allotted for the blood circulation curves (Fig. 6.1 b, c), in the late scintigram the area of pathologic uptake should be kept small (Fig. 6.1 d) so as not to falsify the quotients by including normal tissue. In a very small ROI (like the carpal bones), it can be useful to set a considerably larger reference ROI, since a low counting rate in few pixels in normal bone can lead to statistical problems. The reproducibility of results is good; the coefficient of variation is less than 5 %. In contrast to radiographic diagnosis, plaster casts up to 1 cm in thickness do not influence optical interpretation and quantitative assessment with scintigraphy.

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6 Skeletal Scintigraphy

Fig. 6.1a–d Three-phase scintigraphy of a nondisplaced radius fracture of the right side (600 MBq 99m Tc-HMDP). a Single films of arteriovenous phase in the first 60 seconds after tracer injection. b Graphs of circulation in the regions of interest (ROI) of the partial image c. c Summation image of the arteriovenous circulation in the first 60 seconds after tracer injection with the framed ROI. Alternatively, the early-phase scintigram (taken 2 minutes after tracer injection) can be used to determine the ROI. d Static scintigram 2 hours after tracer injection with the framed ROI. Obvious rise in the calculated quotient.

2 MIN. P.I. Q R/L = 2.8

2 HOURS P.I. Q R/L = 7.6

Biological Foundations Knowledge of the local differences in bone perfusion is important for the interpretation of skeletal scintigrams. A well-developed network of vascular collaterals makes the blood supply in periarticular areas considerably higher than that in the shafts of tubular bones. Their blood supply comes mainly from the bone marrow and is much more likely to be disturbed by dislocated fractures.

Table 6.2 Stages of fracture healing (according to Brand) Stage I: Inflammation U A few hours after the trauma U Local hyperemia Stage II: Repair U Begins a few hours after the trauma U Incorporation of calcium begins on the 3rd–4th day U Maximal reaction after 7–12 days (soft-tissue callus) Stage III: Remodeling U Takes months to years U Transformation of fibrous into laminar bone U With increasing functional use

As a result of the differences in perfusion, 8–10 days after a trauma, for instance, in periarticular areas hyperemia is nearly always present with a relatively higher accumulation of the isotope. A fracture of the shaft also causes reactive hyperemia in the surrounding soft tissues, but not in the affected parts of the bone. Similar mechanisms lead to intense accumulation of the tracer in inflammatory and active degenerative joint diseases. Furthermore, reactive bone formation after a fracture causes tracer accumulation in scintigrams. Fracture healing can be summarized in three stages (Table 6.2). According to the transformation law, a reconstruction process also takes place in the final callus. In the tracer technique, osteotropic radiopharmaceuticals are transported into the osseous metabolism. The scintigraphic image of accumulated tracer in the bone changes according to the different pathophysiologic factors prevailing at different stages of fracture healing. Finally, the fundamental principles underlying tracer uptake under normal and abnormal conditions of the bone have not been entirely clarified. Arnold’s concept appears suitable to correlate theoretical concepts with

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Biological Foundations

empirical clinical data (Table 6.2). A model consisting of two bony compartments, each of which is connected with the blood compartment, offers the following explanation: U One compartment represents weak binding sites on the crystalline surface of the quiescent bone. Tracer clearance from the blood onto the weak binding sites correlates with the intensity of blood flow to the bone. U The second compartment represents strong binding sites, which are formed by amorphous calcium phosphate in newly formed lamellar bone. Tracer clearance in the strong binding sites correlates with new bone formation. The increased tracer clearance during new bone formation is based on an increase in the extraction efficiency. This increase is proportional to the newly-formed lamellar bone, whether callus formation, an osseous tumor, or osteomyelitis. Differentiation can be achieved only with the aid of other imaging procedures and the clinical findings.

capillaries

extravascular space

mineralized bone

Fig. 6.2 Action of 99m Tc-labeled phosphate complexes in the capillaries of the terminal bloodstream. (Modified according to Arnold.) The radiopharmaceutical substance (*) carried in the blood diffuses into the extracellular fluid, which washes over the surface of the bones. The radiopharmaceutical substance, which is not primarily bound to the surface or has been released, returns to the efferent branch of the blood vessel.

Because of the exposure of the patient to ionizing radiation, skeletal scintigraphy demands an appropriate indication. Table 6.3 shows gonadal exposure in comparison to radiographic diagnostic procedures. Table 6.4 lists the radiation doses for different organs, demonstrating that the urinary bladder is the critical organ because of elimination of the radiopharma-

ceutical in the urine. Radiation exposure can be reduced by sufficient diuresis and frequent urination. Skeletal scintigraphy, like other nuclear medicine examinations, is contraindicated during pregnancy and lactation. Lactation constitutes only a relative contraindication, though, since nursing can be resumed without danger two days after such examinations.

Table 6.3 Gonadal exposure in scintigraphy with 555 MBq (15 mCi) 99mTc-MDP compared to radiological diagnostic procedures

Table 6.4 Radiation exposure of different organs in skeletal scintigraphy with 99mTc-MDP. Data apply to an adult weighing 7 0 kg exposed to 555 MBq (15 mCi)

Examination

Skeletal scintigraphy

Gonadal Exposure in mGy/ 555 MBq (rem/15 mCi)

Organ

Radiation Exposure in mGy/ 555 MBq 99mTc-MDP (rem/15 Ci)

Male

Whole body

1.0

(0.1)

Skeleton

5.3–5.7

(0.53–0.57)

Kidneys

6.0

(0.6)

Female

1.8

(0.18)

2.6

(0.26)

Lumbar spine

0.65

(0.065)

0.75

(0.075)

(2.0–4.7)

7.7

(0.77)

3.5

(0.35)

Wall of urinary bladder

20.0–47.0

Pelvis Colon

2.85

(0.285)

10.5

(1.05)

Bone marrow

3.5

(0.35)

Urogram

6.3

(0.63)

6.15

(0.615)

Liver

0.8

(0.08)

Radiography:

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6 Skeletal Scintigraphy

Factors Influencing Scintigraphic Images The main factors that exert a pathophysiological influence on tracer accumulation following trauma are summarized in Table 6.5. Reactive regional hyperemia occurs immediately after a trauma, especially in the extremities. This leads to a diffuse, unspecific increase in tracer accumulation in the area surrounding the fracture in the third phase of skeletal scintigraphy. The focal increase in tracer accumulation around the fracture appears with different intensities and at different times after a trauma. Both factors depend on the localization of the fracture in the skeletal system. Therefore, focal tracer accumulation can be missing in the first few days after a shaft fracture or bony injury of the trunk. Injuries of the soft tissues and ligaments also show reactive regional hyperemia. The quotients are, however, rarely larger than 2.5 and differ from those of a fracture in that the quotients fail to rise or even fall within 24 hours after tracer injection. Tracer accumulation in degenerative joint disease resembles that of tendon and soft-tissue injuries, where early hyperemia is usually missing, unless active osteoarthritis is involved.

Table 6.5 Parameters of skeletal scintigraphy following trauma U U U U U

Time after trauma (in days) Regional hyperemia Injury site Inactivity or immobilization Time after tracer injection (in hours)

During the 2–3 weeks following the trauma, a significant increase in focal accumulation of tracer occurs around the fracture, with the intensity depending on the fracture localization (Fig. 6.3). The intensity of tracer accumulation (the magnitude of the scintigraphic quotient) is also determined by callus formation. In contrast to the skull and the spinal column, callus formation in the shaft of tubular bones is intense. Fractures treated with osteosynthesis show little callus formation and correspondingly low quotients in comparison to conservatively treated or unstable fractures and comminuted fractures with higher quotients. In most fracture locations, the maximum tracer accumulation occurs about 2–3 weeks after the trauma; in shaft fractures, due to pronounced callus formation, it occurs 4–5 weeks after fracture. Thereafter the quotients gradually fall over months until final normalization. Neither age nor sex of the patient influence the scintigraphic image or the magnitude of the quotient. Figure 6.4 shows the course of the calculated factors over time for distal radius fractures. Therapeutic immobilization of an extremity causes increased bone remodeling within the first week, especially around the joints. In spite of increased accumulation of the 99mTc–phosphate complex, there is a negative balance in the mineral content of the bone, resulting in inactivity osteoporosis. The duration and efficiency of immobilization increase this remodeling so that in the scintigram, for example after a 12-week immobilization, a fracture of the scaphoid can no longer be differentiated from the surrounding osteoporotic carpal bones (Fig. 6.5).

log (q) 2.5

hyperemia

total remodeling

new bone formation

osteoporosis quotient 6 5 4 3 2 1 0

2 1.5

quotient 6 5

1

4 3 2

0.5

1 0

0

0 0.6 1.2 1.5 3 6 9 12 14.1 15 18 21 24 27 30 33 36 39 42 45 48 51 54

0

5

10

15 20 25 days after trauma

30

35

Fig. 6.3 Radionuclide accumulation in fractures of different locations. Obvious differences in the intensity of tracer accumulation over time are found initially, in the time and height of the maximal bone remodeling, and during normalization. –˜– = radius,–l– = scaphoid, –¿– = extremity shafts.

days after trauma

Fig. 6.4 Diagram of regional bone-remodeling factors after distal radius fracture. The pathophysiologic factors (osteoporosis, hyperemia, new bone formation) and the entire remodeling process of the bone in the first weeks following trauma are shown.

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Indications for Skeletal Scintigraphy

a

b

PALMAR 2 WEEKS

c

PALMAR 4 WEEKS

d

PALMAR 7 WEEKS

Fig. 6.5 a–d Normal healing process after fracture of the scaphoid (555 MBq 99m TcHMDP). a Intensive focal tracer accumulation two weeks after the trauma. b Decreasing accumulation in the fractured area from the third to fourth week after trauma. c, d Increasing immobilization in a plaster cast leads periarticularly to diffuse osseous remodeling. These changes are caused by inactivity osteoporosis and do not affect fingers IV and V, which are outside of the cast and can be moved freely.

PALMAR 12 WEEKS

As mentioned above, arthritis, osteomyelitis, and bone tumors scintigraphically resemble a fresh fracture because they also lead to formation of amorphous calcium phosphate in fibrous bone and to an increased regional blood supply. Further differentiation is, therefore, only possible by synoptic evaluation, including medical history, clinical findings, and radiographic

examination. Only the high increase in tracer accumulation within the first 2–3 weeks after the trauma is typical of a fresh fracture and can, therefore, be used for differentiation in unclear cases. Initial stages of arthritis, as well as incomplete fractures, can often be seen in scintigrams when radiographs are still equivocal.

Indications for Skeletal Scintigraphy The wide spectrum of indications can be summarized in a few fundamental points. Exclusion of bony lesions: This particular indication is very important in traumatology since no other imaging procedure is able to exclude a pathologic osseous process in general, and a fracture in particular, as well as scintigraphy (Fig. 6.6). With the exception of the two following constellations, skeletal scintigraphy represents a highly sensitive method for confirming pathologic bone remodeling. U A reliable diagnosis can be made only if the time between trauma and examination is sufficiently long.

U

In the diagnosis of inflammation and tumors, only osteoplastic processes can be excluded, while pure osteolyses often cannot be identified scintigraphically because of the lack of new bone formation.

Discrepancy between clinical symptoms and radiographic findings: The large variance in skeletal morphology limits the diagnostic reliability of radiographs, even in the presence of a pathologic finding. In this situation, the high detection rate of skeletal scintigraphy presents advantages because intensive tracer accumulation as a sign of repair processes can be seen when the radiograph still appears normal.

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6 Skeletal Scintigraphy

U

U

U

U

Fig. 6.6 Scintigraphic exclusion of a fresh osseous injury. Normal late-phase scintigram of a 12-year-old girl taken after three weeks of immobilization for a suspected scaphoid fracture of the left hand (160 MBq 99m Tc-HMDP). Diffuse increase in tracer uptake near the joints of the left hand, as well as reduced uptake in the epiphyses due to incipient inactivity osteoporosis as a result of immobilization.

When a scaphoid fracture is suspected, rarer fractures of the other carpal bones can easily be overlooked in projection radiography (Fig. 6.7). Damaged cartilage cannot be recognized in radiographs, but can be diagnosed with certainty scintigraphically on the basis of the accompanying bone reaction. Scintigraphy is similarly reliable in the diagnosis of incomplete fractures and injuries at the level of subchondral bone plate. As indicated in a recent study, not all carpal injuries can be identified radiographically, not even with CT.

Screening and staging in polytrauma, systematic skeletal and joint diseases, and osseous metastases: U After polytrauma, aside from life-threatening injuries, additional traumatic injuries can easily be overlooked. Whole-body skeletal scintigraphy is a suitable screening method in such cases and provides highly useful additional diagnostic information, especially in the extremities. U Scintigraphy offers the same screening advantages in systemic inflammatory diseases of the skeleton, which often show early manifestations in the distal joints of the upper and lower extremities.

7 DAYS AFTER TRAUMA

2 MIN P.I. Q L/R = 1.2

2 HOURS P.I. Q L/R = 2.1

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Fig. 6.7 a–e Scintigraphic diagnosis to localize carpal trauma. Suspicion of scaphoid fracture after a fall on the left hand, which could not be confirmed by a follow-up radiograph two weeks later. The three-phase scintigraphy (620 MBq 99m Tc-HMDP) performed evaluate to severe pain reveals–aside from an unremarkable scaphoid–intensive tracer uptake near the pisiform or triquetral bones. Reexamination of the radiographs confirms an avulsion fracture.

Indications for Skeletal Scintigraphy

2 MIN. P. I.

2 MIN. P. I.

PALMAR

PLANTAR

3 HOURS P. I.

3 HOURS P. I.

PALMAR

U

U

Fig. 6.8 Scintigraphic evidence of systemic inflammation. A 58-year-old patient with persisting complaints in the left thumb after a minor trauma. Clinically, slight but painful swelling in the trapeziometacarpal joint. Radiographs are unremarkable; MRI shows a posttraumatic joint effusion. Two-phase scintigraphy reveals synovitis of the trapeziometacarpal joint in the soft-tissue phase, as well as tracer uptake in the second metacarpophalangeal joint. Suspicion of a systemic inflammatory disease is confirmed by complementary imaging of the feet, showing numerous tracer accumulations. On the basis of scintigraphic findings, the patient was referred to a rheumatologist for further diagnosis and treatment.

PLANTAR

Conversely, easy scintigraphic whole-body examinations can sometimes provide the correct interpretation of a local finding in the hand as a manifestation of a systemic disease (Fig. 6.8). Due to methodologic problems, CT and MRI cannot presently be employed as routine procedures. The bones of the hand have little relevance in the diagnosis of bone metastases.

Suspicion of delayed posttraumatic or postsurgical convalescence (ischemia, osteonecrosis, osteomyelitis, algodystrophy): Radiographic and clinical findings are generally sufficient for recognition of pathologic consolidation of fractures. Scintigraphy offers further differentiation only in the following unclear complaints or radiographic findings in the posttraumatic or postsurgical phase: U Disturbed circulation in bone fragments and implants, a preliminary stage of osteonecrosis, can be diagnosed scintigraphically. The disorderly new bone formation within the necrotic bone tissue results in intensive tracer accumulation, which must not be misinterpreted as callous in a healing fracture. Prognoses can only be made with reservations and under consideration of the radiographic results.

U

U

In diagnosis of osteomyelitis, scintigraphy primarily provides exclusion. Interpretation can be very difficult after fracture or osteotomy. This difficulty also applies to four-phase scintigraphy and specific leukocyte scintigraphy. In the diagnosis of nonunion (Chapter 20) and when algodystrophy is suspected (Chapter 32), scintimetry within the scope of three-phase scintigraphy provides complementary information.

Determining the relative age of a fracture: Sometimes radiographic results are inconclusive in the presence of previous damage or degenerative changes when a fresh trauma is to be excluded. Three-phase scintigraphy can provide diagnostic differentiation as follows: U Older processes generally do not demonstrate regional hyperemia in the first and second scintigraphic phases. U A rise in the scintimetrically determined quotients (lesion vs. region of reference) verifies a fresh bone injury in the follow-up examination 8–10 days after the first examination and within the first 3 weeks after the trauma.

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6 Skeletal Scintigraphy

Fig. 6.9 a, b Scintigraphic findings at different ages. a A 7-month-old child. Late-phase images of both hands and arms, lateral view of the skull, and the bony thorax. b A 10-year-old child. The left side shows the bloodpool phase; on the right, the late phase. (Courtesy of K. Hahn, MD, Munich.)

a

b

Scintigraphic Peculiarities among Children Bone growth takes place in the epiphyseal lines. Depending on the stage of maturity, the skeletal areas with intensive bone growth vary greatly in appearance.

Radiopharmaceuticals: Either 99mTc-MDP or 99mTc-DPD is employed in scintigraphy. The dose and activity level depend on the child’s body weight (Table 6.6).

Examination Technique in Children Scintigraphy of the hands of infants and children is best performed with a hand on each side of the skull. This simultaneously visualizes the entire arm, the lateral aspect of the skull, and the thorax either in anterior or in posterior projection (Fig. 6.9). Scanning times of the hands must be identical to ensure reliable comparability. Images are taken in the sitting position with older children. The hands and forearms lie firmly on the detector surface in the middle of the camera during acquisition of the bloodpool image and the late-phase image. Strictly symmetrical positioning is very important, because only then differences in the pattern of tracer accumulation can be reliably demonstrated scintigraphically. The quality characteristic for images taken in lying or sitting position is that the distal epiphyseal lines of the radius and ulna appear separately.

Table 6.6 Doses of 99mTc-MDP for skeletal scintigraphy of children (recommendations of the Pediatric Task Group of EANM) Adult dose of 500 MBq weight-dependent reducing factor Body Weight (kg)

Reducing Factor

Body Weight (kg)

Reducing Factor

4

0.14

28

0.58

8

0.23

36

0.71

12

0.32

44

0.80

16

0.40

52

0.90

20

0.46

60

0.96

24

0.53

68

0.99

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Scintigraphic Peculiarities among Children

Pattern of Tracer Accumulation in Skeletal Scintigraphy Images taken in the bloodpool phase immediately after injection of the radiopharmaceutical substance (the first phase is not shown), as well as the mineralization phase at least three hours later, are depicted in Fig. 6.9. The impulse rate for the individual images is 50 000 to 100 000 impulses when using a high-resolution collimator. It is very important to note that considerable variations in normal skeletal scintigrams can be seen in growing children.

Further Reading Arnold JS. Mechanisms of fixation of bone imaging radiopharmaceuticals. In: Billinghurst MW, Colombetti LG, eds. Studies of Cellular Function using Radiotracers. Boca Raton, FL: CRC Press; 1982. Becker W. Diagnosis of inflammatory bone and joint disease – Scintigraphic techniques. In: Höfer R, Bergmann H, Sinzinger H, eds. Radioactive Isotopes in Clinical Medicine and Research. Stuttgart: Schattauer; 1993. Brand RA. Fracture healing. In: McCollister-Evarts C, Carlson DH, eds. Surgery of the Musculoskeletal System. New York, NY: Churchill Livingstone; 1983:65–87. Dee P, Lambruschi PG, Hiebert JH. The use of Tc-99m MDP bone scanning in the study of vascularized bone implants: Concise communications. J Nucl Med. 1981;22:522–525. Ganel A, Engel J, Oster Z, Farine I. Bone scanning in the assessment of fractures of the scaphoid. J Hand Surg. 1979;4:540–543. Groves AM, Cheow HK, Balan KK, Bearcroft PW, Dixon AK. 16 detector multislice CT versus skeletal scintigraphy in the diagnosis of wrist fractures: Value of quantification of 99Tcm-MDP uptake. Br J Radiol. 2005;78:791–795. Hahn K, Fischer S, Gordon I. Atlas of Bone Scintigraphy in the Developing Pediatric Skeleton. The Normal Skeleton, Variants and Pitfalls. Heidelberg: Springer; 1993. Hahn K, Fischer S, Gordon I. Registration and display of the combined bone scan and radiograph in the diagnosis and management of wrist injury. Eur J Nud Med. 1991;18:752–756. Israel O, Gips S, Jerushalmi J, Frenkel A, Front D. Osteomyelitis and soft-tissue infection: Differential diagnosis with 24 hour/4 hour ratio of Tc-99m MDP uptake. Radiology. 1987;163:725–726.

Lisbona R, Rennie WRJ, Daniel RK. Radionuclide evaluation of free vascularized bone graft viability. Am J Roentgenol. 1980;134: 387–388. Love C, Din A, Tomas M, Kalapparambath T, Palestro C. Radionuclide bone imaging: An illustrative review. Radiographics. 2003;23: 341–358. Matin P. The appearance of bone scans following bone fractures, including immediate and long-term studies. J Nucl Med. 1979;20: 107–120. Maurer AH, Holder LE, Espinola DA, Rupani HD, Wilgis EF. Threephase radionuclide scintigraphy of the hand. Radiology. 1983;146: 761–775. Maurer AH. Nuclear medicine in evaluation of the hand and wrist. Hand Clin. 1991;7:183–200. McCall IW, Sheppard H, Haddaway M, Park WM, Ward DJ. Gallium-67 scanning in rheumatoid arthritis. Br J Radiol. 1983;56:241–243. Rhinelander FW. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg. 1968;50A:784–900. Rolfe EB, Garvie NW, Khan MA, Ackery DM. Isotope bone imaging in suspected scaphoid trauma. Brit J Radiol. 1981;54:762–767. Smith ML. Quantitative Tc-99m diphosphonate uptake measurements. In: Fogelman I, ed. Bone Scanning in Clinical Practice. Heidelberg: Springer; 1987:237–248. Spitz J, Lauer I, Tittel K, Weigand H. Scintimetric evaluation of remodeling after bone fractures in man. J Nucl Med. 1993;34:1403–1409. Spitz J, Becker C, Tittel K, Weigand H. Clinical relevance of whole body skeletal scintigraphy in multiple injury and polytrauma patients. Unfallchirurgie. 1992;18:133–147. Stein F, Miale A, Stein A. Enhanced diagnosis of hand and wrist disorders by triple phase radionuclide bone imaging. Bulletin Hosp Jt Dis Orthop. 1984;44:477–484. Thorpe AP, Murray AD, Smith FW, Ferguson J. Clinically suspected scaphoid fracture: A comparison of magnetic resonance imaging and bone scintigraphy. Br J Radiol. 1996;69:109–113. Tiel-van Buul MMC, van Beek EJR, Dijkstra PF, Bakke AJ, Broekhuizen TH, van Royen EA. Significance of a hot spot on the bone scan after carpal injury - evaluation by computed tomography. Eur J Nucl Med. 1993;20:159–164. Wagner HN Jr., Szabo S, Buchanan J, eds. Principles of Nuclear Medicine. 2nd ed. Philadelphia, PA: Saunders; 1995. Wolff J. Das Gesetz der Transformation der Knochen. Berlin: August Hirschwald; 1892. Young MRA, Lowry JH, Laird JD, Ferguson WR. 99TcmMDP bone scanning of injuries of the carpal scaphoid. Injury. 1988;19:14–17.

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Ultrasonography

7

W. Buchberger, R. Schmitt, G. Christopoulos

High-frequency probes (7.5–15 MHz) provide excellent imaging of the soft tissues of the hand, especially in the carpal tunnel. New developments, such as tissue-harmonic imaging, computed ultrasonography (US), extended-view techniques, and three-dimensional US, have considerably increased imaging possibilities in the small parts of the hand. Present diagnostic indications are: (1) injuries to the tendons, collateral and anular ligaments, (2) pathologic pro-

cesses of the tendon sheaths, (3) nerve-compression syndromes, (4) confirmation of joint effusion and inflammatory joint diseases, (5) detection and staging of soft-tissue tumors and other space-occupying lesions, and (6) evaluation of vascular pathologies with color-coded duplex US. Although considerably limited in visualization of bone abnormalities, US offers the advantages of wide availability and ability to record functional movement patterns.

Physical Principle U

U

Definition: Ultrasonic waves are periodic oscillations of particles around their resting positions that spread spatially in elastic waves. Medical US uses acoustic frequencies from 1 to 15 MHz that are beyond the range of human hearing, which is about 1–20 kHz. The conduction velocity of ultrasonic waves depends on the density of the material being examined: in water it is 1490 m/sec, in parenchymal organs (liver, spleen, kidneys, etc.) and muscle about 1580 m/sec, and in bone 3360 m/sec. Acoustic impedance and interface reactions: The decisive physical property for imaging is the acoustic im-

U

U

7.5MHz

scattering

diffraction

transmit

transmission

reflection (receive) absorption

refraction

Fig. 7.1 Schematic of the different ultrasonic phenomena seen at an acoustic interface. The physical terminology is explained in the text.

pedance, since interfaces between two adjacent tissues with different conductivity can change direction and quality of the wave. Physically, the acoustic impedance Z is the product of the density of the material σ and the acoustic-wave velocity c (Z = σ×c). At acoustic interfaces, reflection, refraction, diffraction, diffusion, and absorption take place (Fig. 7.1). Since only the portion of acoustic waves reflected back to the probe without deviation from the plane of incidence can be used for diagnosis, the energy at the acoustic-wave receiver is less than 1 % of the transmitted energy. Producing, transmitting, and receiving: The production of acoustic waves is achieved by means of the piezoelectric effect. The energy of a high-frequency electric alternating current applied to a quartz crystal causes rhythmic changes in the crystal volume that are transmitted into the surroundings in the form of acoustic ultrasonic waves. The reception of acoustic waves functions in reverse as a “negative piezoelectric effect.” The energy of an acoustic wave (acoustic wave pressure) is taken up by the quartz crystal, causing a change in the electric charge on the surface. In ultrasonographic imaging, these electric impulses are fed into a computer system, which, with the aid of a mathematical algorithm, computes scans in real time.

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B-scan Ultrasonography

B-scan Ultrasonography U

U

intensity

U

Image origin: In B-scan procedures (B for brightness), two-dimensional scans are produced in real-time mode and depicted as an image in various shades of gray corresponding to the wave intensity. A US probe contains numerous crystals that are arranged next to one another and alternately serve as transmitter and receiver. In the echo-impulse procedure, short wave impulses lasting 0.000001 second are transmitted in rapid succession. In comparison, the reception time for the reflected echo is very long: the transmission time constitutes only 0.1 %, and the reception time 99.9 % of the total time required to produce an image. The image matrix is determined by the lateral and axial position encoding, as well as by the amplitude of the reflected acoustic waves. Lateral position encoding is achieved by identifying the receiving piezoelectric

intensification (DCG) U

decay

depth

Fig. 7.2 Relationship between acoustic energy and depth of penetration. The acoustic energy (ordinate) decreases exponentially with the depth of penetration (abscissa). Electronic equalization of intensity with depth gain compensation (DGC).

crystal. For depth localization (axial position encoding), the echo delay (sum of the transmission and reception times) correlates with the position of the point (ultrasound reflection) on the monitor. This time–position calculation causes brief echo-delay times to appear close to the probe in the upper portion of the image, whereas long echo-delay times are represented far from the probe in the lower section of the image. The echo intensity is determined by the amplitude of the acoustic wave. High amplitudes produce a bright reflex point, and low amplitudes produce a dark point. Depth compensation: The transmitted acoustic waves weaken with increasing distance within the body (i.e., the wave amplitude decreases), and the reflected echo energy becomes correspondingly weaker. The reduction in intensity increases exponentially with the depth of penetration. To achieve diagnostically assessable ultrasonographic information, compensation for the signal far from the probe must be made in the form of electronic enhancement of the echo signal at the receiver site (Fig. 7.2). Artificial brightness enhancement (DGC = depth gain compensation) of echoes received from deep tissue layers can be performed automatically or manually by the examiner. Transducer technology: The probe converts electrical energy into mechanical vibrations and vice versa by means of piezoelectric crystals. The form of the ultrasonic beam is essentially determined by the probe design. Mechanical probes use oscillating or rotating transducers with a sector-shaped acoustic beam or anular-array constructions with ultrasonic elements arranged in concentric circles. Electronic-array probes have numerous ultrasonic elements arranged in a plane, and these elements can be controlled electronically. A linear or curved array of the transducer surface produces rectangular or sector-shaped acoustic fields. Sector scanning is also possible with phased-array probes in which the form of the sound beam can be achieved through time-offset excitation of the ultrasonic elements.

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7 Ultrasonography

Doppler Ultrasonography and Color-coded Doppler Ultrasonography U

U

U

U

The Doppler effect: If sound waves are reflected onto a moving interface (as are, for example, erythrocytes in flowing blood), the frequency increases when the interface is approaching the probe and decreases when it is retreating from the sound source. When the velocity of the reflecting interface is considerably lower than that of the sound waves, the difference between α the transmitting and receiving frequencies is fD= 2 ν ⋅cos c where ƒ is the transmission frequency, c is the sound velocity, v is the velocity of the interface, and ¥ is the angle between the movement vector of the reflecting structure and the effective direction of the ultrasonic beam. At a sound transmission frequency of 3 MHz and a sound velocity of 1500 m/sec, one can assume, for example, from a Doppler shift ƒD of 4 kHz, a bloodflow velocity v of 1 m/sec. The continuous-wave (CW) technique is the simplest method of recording Doppler spectral curves and is based on the continuous transmission of ultrasound waves in the body. The probes have separate ultrasonic elements for transmitting and receiving sound waves. Pulsed Doppler (PD) techniques: Selection of an electronic window for the reception of reflected sound waves makes possible delay-time-dependent depth selection; that is, the examiner can arbitrarily choose a Doppler sample volume along the ultrasonic beam. The pulse-repetition frequency is then determined by the required depth penetration and the maximal measurable flow velocity. Both methods have the disadvantage that the measurement of the Doppler spectrum must occur without imaging support. Duplex US combines B-scan technique with PD to achieve an image-supported choice of the Doppler sample volume. While the scan movements of the

U

U

transducer must be mechanically held stationary in the desired position to enable recording of the Doppler signal, with electronic array probes a nearly simultaneous recording of the B-image and the Doppler spectral curve is possible. Color-coded duplex US uses real-time gray-scale images over which two-dimensional images showing color-coded blood flow can be superimposed. The image can be either frequency-coded or amplitudecoded (power Doppler). Although the frequencycoded image contains information about velocity and direction of blood flow, the power Doppler mode, which does not depend on the ultrasonic angle, offers optimal visualization of the vascular architecture. Ultrasonographic contrast agents based on microbubbles, i.e., microscopically small gas bubbles ranging in size from 2 to 8 µm, present one possibility for enhancing the US signal. This characteristic is based on the nearly complete reflection of ultrasonic waves from their surfaces and, even more, on their resonance. The phenomenon can be used in the form of second-harmonic imaging, which employs only the overtones, i.e., ultrasonic waves with a frequency double that of the transmitted frequency, resulting in an improved signal-to-noise ratio. Unlike contrast-enhanced techniques in angiography, CT, and MRI, duplex US cannot provide plain and echo-contrastenhanced images of the capillary bed in normal and abnormal tissues, as the flow velocity in the capillaries is too slow for this purpose. One possibility for overcoming this limitation involves imaging by bursting the gas bubbles with an ultrasonic beam of high-amplitude echoes (stimulated acoustic emission, SAE).

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Special Prerequisites for Ultrasonographic Examination of the Small Parts of the Hand

Special Prerequisites for Ultrasonographic Examination of the Small Parts of the Hand Because of their anatomic characteristics, examination of the soft tissues of the hand places especially high demands on the spatial and contrast resolution of modern ultrasonographic equipment. U Spatial resolution: Spatial limiting resolution, i.e., the smallest size of structures that can be differentiated from one another, is influenced by various factors in US imaging. The resolution in the z direction (axial resolution) depends directly on the pulse duration and, thereby, on the frequency of the transmitted sound waves. Simultaneously, the depth penetration decreases with increasing transmission frequency because the attenuation of the sound waves through absorption, refraction, and scatter is directly proportional to the sound-wave frequency. The resolution in the y direction (lateral resolution) and in the x direction (slice-thickness resolution) is determined by the focusing of the acoustic beam and the position in the acoustic field. U Wide-band frequency probes operate with a wide frequency spectrum, e.g., between 5 MHz and 12 MHz. Whereas conventional probes with a single frequency band always represent a compromise between resolution and depth penetration, state-of-the-art probes combine high axial resolution, good depth penetration, and homogeneity of the B-mode image. U Focusing of the acoustic beam at all depths is a prerequisite for high lateral resolution and reduction of slicethickness artifacts. With mechanical anular-array probes, the exact electronic focus of the transmitted acoustic beam, as well as a dynamic focus of the reflected acoustic beam, can be selected to provide excellent conditions for ultrasonographic examination of the small parts of the hand. Focusing the electronic array probes is technically challenging, and only the most advanced instruments have solved the problem. Multiarray probes consist of acoustic elements arranged in two planes that can be selectively activated to achieve electronic focusing in the x and y directions. Moreover, with modern instruments numerous focus zones can be chosen without a significant reduction in image calculation. U Contrast resolution and the signal-to-noise ratio, along with the frequency spectrum and the focusing of the probe, are strongly influenced by the acoustic and electrical impedance of the acoustic elements, and also by the acoustic characteristics of the tissue being examined. Absorption, diffraction, and refraction of the acoustic waves at acoustic interfaces, as well as reverberation artifacts, lead to a signal-to-noise ratio that worsens with depth. In contrast, the amplitude of

overtones of the reflected acoustic waves increases with increasing distance from the skin. Modern wideband probes can selectively receive these overtone acoustic waves, resulting in a significant reduction in image noise (tissue harmonic imaging). Another new possibility for improving the contrast–noise ratio and reducing artifacts is offered by real-time compound imaging (computed US), in which B-scan images from different acoustic directions are combined in real time into a two-dimensional scan. Further improvements in contrast resolution are achieved in modern instruments by means of improved signal enhancement, higher dynamic range, and complex signal processing. Extended field of view: The limited field of view of probes used in small-part US examinations makes it difficult to assess muscles, tendons, nerves, and blood vessels, which have to be followed along their entire course over long distances. The field of view can be enlarged by computing a compound image composed of numerous slabs of images achieved by moving the probe over the region of interest. The complex correction algorithms for the translational and rotational movements during imaging require a separate processor. Three-dimensional US: Three-dimensional imaging with image reconstruction in any plane (3D US) provides better visualization of anatomic structures, three-dimensional reconstruction of surfaces and vascular structures, and exact measurement of the volume of space-occupying lesions. Systems available today employ either probes with mechanic volumetric scanning, conventional two-dimensional probes with acoustic or magnetic registration of the probe position during scanning, or electronic matrix probes, which can directly measure volume because of their longitudinal and transverse arrangement of acoustic elements. Three-dimensional US and the extended-fieldof-view technique represent promising methods for improved ultrasonographic assessment of the complex anatomy and pathology of the hand. The technical specifications shown in Table 7.1 must be fulfilled for examination of the small parts of the hand.

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U

Table 7.1 Technical prerequisites U U U

Linear-array probe Frequency of at least 7.5 MHz Near-field focus

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Normal Ultrasonographic Findings The most important structures in the hand that can be assessed by ultrasound are on the palmar aspect and have the following echogenicities: U Tendons and tendon sheaths: Depending on the angle at which the probe is placed, tendons and tendon sheaths appear hyperechoic at a right angle or hypoechoic at an oblique angle. They are characterized by their fibrillar internal structure. The tendons can easily be identified in real time, and their sliding capacity can be assessed when the fingers are moved. The synovial sheath appears in cross-section as a hypoechoic ring and in longitudinal section as a bilateral, band-shaped structure around the tendon. U Ligaments: Ligaments have ultrasound characteristics similar to those of tendons. Most important is the visualization of the ulnar collateral ligament on the proximal joint of the thumb. Not all carpal ligaments can be visualized with sufficient resolution, and the anular and cruciate ligaments of the finger cannot always be visualized. Their integrity can only be indirectly assumed from a normal position of the flexor tendons in relation to the phalanges. U Muscles: Muscles appear as hypoechoic structures with a typical featherlike longitudinal form. The parallel muscle septa and the fascia appear under the appropriate acoustic angle as small, hyperechoic bands. In cross-sectional images, the muscles appear spotted. U Fatty tissue: Fatty tissue is almost exclusively present below the skin in the hand and presents as hyper-

U

U

U

U

U

echoic with some irregular reflexes of different sizes. The fatty layer deep in the carpal canal cannot be effectively visualized with ultrasound. Articular cartilage: Articular cartilage is almost without echo. The fact that articular cartilage can only be well visualized by holding the probe perpendicular to its interfaces explains the inadequate visualization of the radiocarpal and carpal joints by ultrasound. Fibrous cartilage: Fibrous cartilage is principally hyperechoic but plays no role in examinations of the hand because the structures of the triangular fibrocartilage complex cannot be visualized with sufficient resolution. Bones: The large difference in impedance between bone and soft tissues means that only the bone surface can be displayed, as a hyperechoic line with total posterior shadowing. Blood vessels: Arterial lumina are consistently hypoechoic to nonechoic and can be visualized up to the fingertips. Color-coded duplex ultrasound is useful because the flow-induced change in the frequency of the reflected acoustic wave (the Doppler effect) is shown in color. Nerves: Peripheral nerves appear as tubular structures with fibrillar interior architecture that correspond with the nerve fascicles. Their echogenicity depends on the angle at which the acoustic waves reach them, but it is always less than that of tendons. The epineural and perineural myelin sheath is hyperechoic.

Examination Procedure The soft tissues of the hand are completely visualized by the following examination sequences: U Slice 1: The examination begins with a cross-section through the palmar side of the forearm at the level of the distal radioulnar joint, showing the quadratus pronator muscle, the tendons of the flexor digitorum superficialis and profundus, the flexor carpi radialis ulnaris, and the median nerve and the radial and ulnar nerves and arteries (Fig. 7.3 a, b). U Slices 2 and 3: The anatomy of the carpal tunnel with the median nerve and the tendons of the flexor digitorum profundus and superficialis muscles, as well as the flexor pollicis longus muscle and the flexor carpi radialis muscle, is next documented in cross-section at the level of the pisiform and hook of the hamate. The ulnar nerve is located in the proximal section of Guyon’s canal on the ulnar side of the ulnar artery. After its division into a superficial and a deep branch, the ulnar nerve can generally no longer be identified (Figs. 7.4 a, b , 7.5 a, b).

U

U

U

Slice 4: The assessment of the dorsal side of the hand with US is made more difficult by the thin covering of soft tissue. Under optimal conditions, the tendons of the extensor carpi radialis longus and brevis muscles can be seen in cross-section on the radial side over the wrist. On the ulnar side the tendon of the extensor carpi ulnaris muscle, in the middle part the tendons of the extensor digitorum, and finally the tendons of the extensor pollicis longus and extensor digiti minimi muscles can be identified (Fig. 7.6 a, b). The tendons of the brachioradialis muscle, the extensor pollicis brevis, and the abductor pollicis longus muscles come into view on the radial side. Slice 5: The median nerve can be seen toward the palmar surface in relation to the superficial and deep flexor tendons in the longitudinal section through the radius epiphysis and the carpus (Fig. 7.7 a, b). Slices 6 and 7: A further cross-section through the bases of the metacarpals shows the opening of the carpal tunnel and the branching of the median nerve into

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Examination Procedure

a

b

Fig. 7.3 a, b Palmar side of the hand at the level of the distal radioulnar joint. carpi radialis muscle; fcu = tendon of the flexor carpi ulnaris a Anatomic transverse section. muscle; fdp = flexor digitorum profundus muscle and tendon; b Sonographic extended-view transverse section. fds = flexor digitorum superficialis muscle and tendon; Abbreviations: ar = radial artery; au = ulnar artery; apl = tenfpl = tendon of the flexor pollicis longus muscle; nm = median don of the abductor pollicis longus muscle; ecu = tendon of nerve; nu = ulnar nerve; pq = pronator quadratus muscle; the extensor carpi ulnaris muscle; epb = tendon of the R = radius; U = ulna. extensor pollicis brevis muscle; fcr = tendon of the flexor

a

b

Fig. 7.4 a, b Palmar side of the hand at the level of the pisiform. a Anatomic transverse section.

a

b Sonographic transverse section. Abbreviations are as in Fig. 7.3, with additionally S = scaphoid; C = capitate; TR = triquetrum; P = pisiform.

b

Fig. 7.5 a, b Palmar side of the hand at the level of the hook of the hamate. a Anatomic transverse section. b Sonographic transverse section. Abbreviations are as in earlier figures, with additionally apb = abductor pollicis brevis muscle; H = hamate; hh = hook of the hamate; MC = metacarpal; opp = opponens pollicis muscle; T = trapezium; Tz, TZ = trapezoid. Arrows indicate the carpi transversum ligament (flexor retinaculum).

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a

b

Fig. 7.6 a, b Dorsal side of the hand at the level of the radioulnar joint. ecrl = tendon of the extensor carpi radialis a Anatomic transverse section. longus muscle; ed = tendon of the extensor b Sonographic extended-view transverse digitorum muscle; edm = tendon of the extensor section. Abbreviations are as in earlier digiti minimi muscle; ein = tendon of the figures, with additionally brr = tendon of extensor indicis muscle; epl = tendon of the the brachioradialis muscle; ecrb = tendon extensor pollicis longus muscle. of the extensor carpi radialis brevis muscle;

a

b

Fig. 7.7 a, b Sagittal section through the hand at the level of the lunate. a Anatomic sagittal section.

b Sonographic extended-view sagittal section. Abbreviations are as in earlier figures.

Fig. 7.8 Sonographic transverse section through the palmar side of the metacarpus. Abbreviations are as in earlier figures, with additionally iop = interosseus palmaris muscle; lum = lumbricalis muscle.

Fig. 7.9 Sonographic sagittal section along the flexor side of the ring finger with a 14 MHz probe. When the probe is held perpendicularly, the flexor tendons appear hyperechoic (right side of the image); when it is held at an oblique angle, they appear hypoechoic (left side of the image).

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Indications

Fig. 7.10 Sonographic extended-view sagittal section along the extensor side of the middle finger. Abbreviations: ed = tendon of the extensor digitorum muscle; PP = proximal phalanx; MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint; MC = metacarpal; MP = middle phalanx.

three digitales palmares communes nerves. In the metacarpal area, the hypoechoic lumbrical muscles are found radial and somewhat dorsal of the flexor tendons, while the interosseous muscles cannot be clearly identified because of the acoustic shadow of the metacarpals (Fig. 7.8). Cross-sections through the proximal and middle phalanges show the tendons of the flexor digitorum profundus muscle, and laterally the sections of the ligaments of the flexor digitorum superficialis, which are perforated by the tendons of the flexor digitorum profundus muscle. The digitales palmares arteries and nerves, respectively, can be

Indications

Fig. 7.11 High-resolution ultrasound of the surface of the scaphoid. Scan performed at the radial side of the wrist. The bony surfaces of the radial styloid process, the scaphoid, and the trapezium are visualized as continuous surface reflexes. At the level of the radioscaphoid joint compartment, the tendons of the first extensor compartment appear hyperechoic.

identified on both sides of the phalanges within the subcutaneous fatty tissue. Slice 8: In longitudinal sections, the flexor tendons can be easily identified. A clear differentiation between the superficial and the deep flexor tendons is not possible in every case, however, because both flexor tendons are separated by only a thin synovial layer (Fig. 7.9). Slice 9: The extensor tendons are easily identified in longitudinal section over the metacarpals. Distally they become increasingly thinner and radiate into the collateral and central bands of the extensor apparatus at the middle and distal phalanges (Fig. 7.10).

U

U

Table 7.2 Indications for ultrasound examination of the hand

Aside from its function as a screening method for nondefinitive complaints and equivocal findings in radiographs, the following special indications apply for highresolution US examination of the hand (Table 7.2). For evaluation of soft-tissue abnormality, US should be the first sectional imaging procedure applied for the diseases listed in Table 7.2. Visualization is limited in the deep palmar compartments because of absorption of the sound energy by overlying bony and tendinous structures. The collateral and central bands of the extensor apparatus cannot be sufficiently distinguished from the adjacent phalangeal bones; ultrasonographic visualization of the triangular fibrocartilage complex is also limited. At these sites, and for characterization of solid space-occupying lesions, MRI is the method of choice for further diagnosis. Bony erosions caused by arthritic synovial pannus or tumorous lesions can be visualized well with US, though CT and conventional radiography are superior for this purpose. A new indication, not yet evaluated, for US is the evaluation of the scaphoid, which displays a smooth, hyperechoic surface when examined from radial, dorsal, and palmar aspects (Fig. 7.11). According to initial

Trauma Lesions of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb U Injuries of the anular ligaments U Injuries of the tendons U Injuries of the nerves U Occlusion, pseudoaneurysm, thrombosis, arteriovenous fistula of the peripheral arteries U

Search for foreign body Inflammatory diseases Tenosynovitis, tendinitis U Joint effusion, hypertrophic synovitis (pannus) U Rheumatic nodules U

Nerve-compression syndromes Carpal-tunnel syndrome U Ulnar-tunnel syndrome U

Search for occult ganglia Tumor diagnosis Differentiation between cystic and solid tumors U Tumor location in relation to adjacent anatomical structures U Size and spread of tumors U Degree of tumor vascularization U

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reports, an acute scaphoid fracture is revealed as a step in the contour of the surface reflection and by means of hypoechoic surroundings caused by hematoma.

Further Reading Adler RS. The future of biomedical ultrasound: Musculoskeletal system. Ultrasound Med Biol. 2000;26:125–127. Angerer M, Kleudgen S, Grigo B, Bogdahn U. Hochauflösende Sonographie des Nervus medianus – neue sonomorphologische Untersuchungstechnik peripherer Nerven. Klin Neurophysiol. 2000;31:53–58. Bianchi S, Martinoli C, Abdelwahab IF. High-frequency ultrasound examination of the wrist and hand. Skeletal Radiol. 1999;28: 121–129. Bianchi S, Martinoli C, Sureda D, Rizzatto G. Ultrasound of the hand. Eur J Ultrasound. 2001;14:29–34. Bronstein AJ, Koniuch MP, van Holsbeeck M. Ultrasonographic detection of thumb ulnar collateral ligament injuries: A cadaveric study. J Hand Surg. 1994;19A:304–312. Buchberger W. Radiologic imaging of the carpal tunnel. Eur J Radiol. 1997;25:121–127. Canpani F. The latest in ultrasound: Three-dimensional imaging. Part I. Eur J Radiol. 1998;27:179–182. Calliada F, Campani R, Bottinelli O, Bozzini A, Sommaruga MG. Ultrasound contrast agents: basic principles. Eur J Radiol. 1998;27: 157–160. Chen P, Maklad N, Redwine M, Zelitt D. Dynamic high-resolution sonography of the carpal tunnel. Am J Roentgenol. 1997;168: 533–537. Downey DB, Fenster A, Williams JC. Clinical utility of three-dimensional US. Radiographics. 2000;20:559–571. Giuseppetti GM, Baldassarre S, Marconi E. Color doppler sonography. Eur J Radiol. 1998;27:254–258.

Hergan K, Mittler C, Oser W. Ulnar collateral ligament: Differentiation of displaced and nondisplaced tears with US and MR imaging. Radiology. 1995;194:65–71. Hoglund M, Tordai P. Ultrasound. In: Gilula LA, Yin Y, eds. Imaging of the Wrist and Hand. Philadelphia, PA: Saunders; 1996:479–498. Hutchinson DT. Color duplex imaging: Applications to upper extremity and microvascular surgery. Hand Clin. 1993;9:47–57. Jacobson JA. Musculoskeletal ultrasound and MRI: Which do I choose? Semin Musculoskelet Radiol. 2005;9:135–149. Keogh CF, Wong AD, Wells NJ, Barbarie JE, Cooperberg PL. High-resolution sonography of the triangular fibrocartilage: Initial experience and correlation with MRI and arthroscopic findings. Am J Roentgenol. 2004;182:333–336. Lin J, Fessell DP, Jacobson JA, Weadock WJ, Hayes CW. An illustrated tutorial of musculoskeletal sonography: Part I. Introduction and general principles. Am J Roentgenol. 2000;175:637–645. Lin J, Jacobson JA, Fessell DP, Weadock WJ, Hayes CW. An illustrated tutorial of musculoskeletal sonography: Part II. Upper extremity. Am J Roentgenol. 2000;175:637–645. Martinoli C, Pretolesi F, Crespi G et al. Power doppler sonography: clinical applications. Eur J Radiol. 1998;27:133–140. Moschilla G, Breidahl W. Sonography of the finger. Pictoral essay. Am J Roentgenol. 2002;178:1451–1457. Newman JS, Laing TJ, McCarthy CJ, Adler RS. Power Doppler sonography of synovitis: assessment of therapeutic response-preliminary observations. Radiology. 1996;198:582–584. Rizzatto G. Ultrasound transducers. Eur J Radiol. 1998;27:188–195. Vails R, Melloni P. Sonographic guidance of needle position for MR arthrography of joints. Am J Roentgenol. 1997;169:845–847. van Holsbeeck M, Introcaso JH. Sonography of the elbow, wrist and hand. In: van Holsbeeck M, Introcaso JH, eds. Musculoskeletal Ultrasound. St. Louis, Mo: Mosby; 1991:285–296. Wells PNT. Physics and instrumentation. In: Goldberg BB, Pettersson H, eds. Ultrasonography. Oslo: The NICER Institute; 1996:1–31.

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8

Computed Tomography R. Schmitt, S. Froehner

In the multislice spiral technique, computed tomography (CT) acquires nearly isotropic voxels. With volume acquisition by means of thin slices, between 0.5 and 1. 0 mm of thickness, the process of scanning the hand is primarily necessary to only one plane: the axial plane on the carpus, the oblique-sagittal plane on the scaphoid, and the sagittal plane on the metacarpus and the fingers. Multiplanar reconstruction (MPR) slices in all other planes as well, as three-dimensional surface views, can be calculated from the dataset. Computed tomography provides high-resolution sec-

tional views of the skeleton of the hand that display the fine trabecular bone structure, the compact bone, and the subchondral bone plate in an edge-enhanced reconstruction algorithm. The main indications for CT are intra-articular radius fractures and fractures of the scaphoid and uni- or multilocular fractures of the other carpal bones, especially when complex trauma is involved. Other important indications are evaluation of scaphoid nonunion and identification of initial stages of osteoarthritis.

General Principle of CT During the scanning process, the x-ray tube (the radiation source) and the detectors (the image-recording system) opposite it rotate around the patient in the same direction. During a rotation of 360°, the examined scan plane is irradiated up to 1000 times from different directions. For each of these projectional views, the result is an intensity distribution of the radiation on the opposite side of the object being examined through the tissuedependent absorption of the x-ray energy. This process

results in a projection. The data acquired in the different projections are computer-processed as follows: First the data are assigned to a reference value and then to a logarithmic value; then the software executes the process of convolution. The convoluted projections are calculated back onto a picture carrier at the same angle ¥ at which they were taken. The final sectional image is formed by the overlapping backprojections.

Spiral CT Technique Spiral CT scanning achieves uninterrupted data collection from the object examined and produces a threedimensional dataset (a volume dataset) by means of simultaneous rotation of the tube–detector system and movement of the examination table at a defined speed. The tube focus moves in a spiral on a virtual cylinder around the center of rotation. The examined volume is completely recorded when the feed speed of the examining table is greater than the quotient of the slice thickness and the rotation speed of the tube. The relationship between the magnitudes of these two movements is defined as the relationship of the table feed per tube rotation to the slice collimation–the pitch factor. For radiation protection, a pitch factor between 1.2 and 1.5 is preferred to scan the examined volume with gaps. The apparent gaps in the data are filled by means of mathematic interpolation to achieve complete image

datasets. The computed views appear as images, as when a complete dataset is acquired, despite a different slice profile. Reconstruction algorithms are used to calculate the image data. Static cross-sectional images in strict axial orientation are calculated with these algorithms from the values measured during the spiral scanning process. Image reconstruction thus comprises first the interpolation process, then convolution and backprojection. In the multislice spiral CT technique, data for image reconstruction, as well as information for calculating several images in the longitudinal axis of the body, are collected per tube–detector rotation. In this type of scanner, the detector elements are arranged over an area. The detector ring is filled with detector elements arranged in several rows, e.g., 24, 32 or 64 rows of detectors installed next to each other, in the z direction. Depending on the scanner type, the detector ele-

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ments are arranged either symmetrically or asymmetrically (adaptive array) within the rows. The principle of the multislice spiral CT is to occupy several rows of de-

tectors with the collimated fan beam, so that the original slice thickness depends primarily on the detector geometry.

Imaging Parameters Spatial Resolution The number of image “dots” (pixels) per slice in CT is generally 512 × 512. These dots represent the two-dimensional image subunit of a three-dimensional volume element (voxel) from the patient examined (Fig. 8.1). For CT of the hand, a field of view (FoV) of 60 mm is used for diagnostic imaging of the scaphoid, or 80 mm for the entire carpus. From these geometric scan parameters in the x–y plane, a theoretical in-plane resolution of 0.12 × 0.12 or 0.16 × 0.16 (edge length of the voxel) can be calculated. The spatial resolution of CT is between 2 and 5 line pairs per mm (Lp/mm). The slice thickness represents the third spatial plane of the volume element. In multislice spiral CT, the collimated slice thickness must be differentiated from the calculated slice thickness. The most common values for collimated slice thicknesses in CT of the hand are 0.5 mm, 0.75 mm, and 1 mm (rarely 2 mm). As a minimal value, the calculated effective slice thickness can indicate the collimated thickness, but it is usually calculated with a higher value or is combined into thicker slices, in the so-called cluster technique. Axial images can be computed for any point in the z direction from the volume dataset. With prescribed slice thickness, it is advantageous to reduce the distance between the centers of the images so that a dataset from the overlapping axial images results. The so-called increment specifies the degree of overlap between the axial

slices in spiral CT. For example, the increment is 0.6 when slices of 0.5 mm thickness are calculated at distances of 0 . 3 mm each.

Density Resolution The degree of x-ray attenuation is described by the absorption coefficient and coded per voxel or pixel by means of a gray scale. The magnitude depends on the material. For each pixel a CT density value is determined that is proportional to the absorption coefficient. The unit of measurement for the CT density value is the Hounsfield unit (HU), which was calibrated on a scale between the values 0 for water, −1000 for air, and +1000 for the densest bones (Table 8.1). The human eye can differentiate only about 30 gray tones. For that reason, the so-called window technique is used in CT image display, as in other digital imaging procedures, in which a certain freely chosen CT range of values is represented in the entire gray scale. The window determines the recorded range of CT values coded in shades of gray. The center of the window represents the middle of all density values displayed on the gray shade. The choice of window depends on the clinical objective. Recommended window values in CT of the hand are: U A window with 4000 HU and center with 1200 HU for the assessment of bony structures U A window with 400 HU and center with 60 HU for the assessment of soft tissues

Table 8.1 CT density values in Hounsfield units (HU) patient volume slice thickness

image plane

scan

voxel

Density Value (HU)

Air

−1000

Fatty tissue

reconstruction

edge length

Tissue

pixel

Fig. 8.1 Relationship between volume element and image element. The volume of an element of tissue (voxel) is calculated from the slice thickness and the in-plane area with edge lengths, which are specified by the scan field of view and the matrix size. After the reconstruction process, the image element (pixel) represents the voxel with a shade of gray. The partial-volume effect results from the inhomogeneity of the densities within the voxel.

−100

Water

0

Muscle

45

Cancellous bone Cortical bone

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150 >250

Examination Techniques for CT of the Hand

Limitation of the Spatial Bandwidth

Artifacts in CT Imaging Out-of-Field Beam-Hardening Artifacts These artifacts appear as dark bands between objects with high CT density. The cause is alteration of the energy spectrum of polychromatic x-rays when they pass through the examined slice. Interfaces between bones and soft tissues are problematic, especially when beam hardening occurs during sagittal slice acquisition in the hand, which is caused by the forearm bones and is outside the scan volume of interest (“out-of-field” artifact). Fortunately, this type of artifact can often be avoided with multislice spiral CT of the hand by the primarily axial alignment of the acquisition plane. The phenomenon can be minimized technically by calibrating the spectrum, increasing the tube voltage, and prefiltration of the beam.

The CT modulation transfer function (MTF) can cause an apparent enlargement of anatomically small and dense structures. Fine fracture lines within trabecular bone can be masked, for example. High-resolution scanning methods reduce this artifact. Use of an appropriate image window may partially correct this bandwidth artifact.

Partial-Volume Effect If two anatomic structures with different CT densities are located within one voxel, their different densities will be equalized by the reconstruction process, and one pixel with a median gray value will be computed in the reconstructed image. Partial-volume artifacts can be reduced by volume acquisition of slices with a thin effective slice thickness and a large image matrix.

Examination Techniques for CT of the Hand Technical aspects of examination techniques used in spiral CT are explained below.

Positioning To acquire axial slices, the patient, wearing a lead apron, stands next to the CT gantry (Fig. 8.2 a). The patient’s forearm and hand are placed in pronation on a bocollo 10 cm high so that the forearm–middle-finger axis is colinear and also the examined volume of the carpus is in the center of the gantry. For examination of the scaphoid, the patient lies prone on the CT table and elevates the arm to be examined over his or her head. The pronated hand lying colinear to the forearm is positioned so that the forearm axis is at an angle of about 45° to the longitudinal dimension of the table (Fig. 8.2 b). The scaphoid and the slightly abducted thumb are then parallel to the scanning plane, which can be checked with the laser. CT examination of the metacarpals and fingers is best performed in sagittal slices, which are parallel to the longitudinal axis of the phalanx (Fig. 8.2 c). Out-offield beam-hardening artifacts are best avoided by having the patient perform ulnar inclination of the wrist for examination of the index and middle fingers and radial inclination for examination of the ring and little fingers. This maneuver puts the forearm outside the scan plane. For all positioning techniques, the hand and the forearm should be securely fixed to the CT table with wide adhesive strips. Positioning pads increase the patient’s comfort and help to avoid movement artifacts.

Planning Images The localizers or “scouts” are acquired coronally in each case. A scout length of 15 cm in the z direction is usually sufficient. After electronic magnification on the screen, the examined volume is defined by drawing in the starting line and the end of the scan, as well as by determining the scan FoV by means of two lateral lines. In CT of the scaphoid, it should be confirmed from the planning image that the scaphoid is aligned parallel to the scan plane (Fig. 8.3). If necessary, the position should be corrected and the scout image repeated.

Acquisition Parameters and Dose Typical acquisition parameters for CT examination of the wrist are a tube voltage of 120 kV and a current-time product of 200–300 mAs. Depending on the CT scanner type, X-ray exposure is 15–30 mSv. Low-dose CT examinations with a voltage of 80 kV and a current–time product of 100 mAs are currently being tested for their diagnostic usefulness in the skeleton of the hand. In examinations of the hand with a single-slice scanner, a slice thickness of 1 mm with a pitch factor of 1.3 and a reconstruction increment of 0.7 mm are recommended. For multislice spiral scanners, the following slice thicknesses are typical: 2 × 0.5 mm, 4 × 0.5 mm, 8 × 0.5 mm, 16 × 0.5 mm, 64 × 0.4 mm, or 4 × 0.75 mm, 8 × 0.75 mm, 16 × 0.75 mm, and 64 × 0.5 mm. In this case, the pitch factor should also be set at about 1.3 and the reconstruction increment at 60–70 % of the calculated slice thickness.

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a

a

b

b Fig. 8.3 a, b CT of the scaphoid. a Positioning the hand at a 45° angle to the longitudinal axis of the trunk brings the scanning plane of the scaphoid parallel to its longitudinal dimension, as shown on the planning image (localizer). b Normal CT finding in an oblique-sagittal slice through the scaphoid.

c Fig. 8.2 a–c Positioning techniques for CT of the hand. a Positioning for axial slices through the distal forearm and the wrist. The patient stands next to the gantry. b Positioning for oblique-sagittal slices through the scaphoid. The light-beam localizer is positioned at an angle of 45° to the longitudinal axis of the forearm. The patient lies in a prone position. c Positioning for sagittal slices through the metacarpus and/or the fingers. Patient lies prone. Note the radial inclination, which is preferred for examination of the fourth and fifth fingers.

Depending on the constitution of the examined hand, for axial slices the field of view is set at a diameter of 60–80 mm. A larger FoV of the hand leads to a significant reduction in spatial resolution. For examination of the scaphoid, the oblique-sagittal slices should be limited to an FoV of 60 mm.

Intravenous administration of 100–150 ml of a nonionic contrast medium is necessary only in the presence of inflammation or tumors or for CT angiography.

Image Computation High-resolution image reconstruction is obligatory for CT imaging of the hand. Since CT is usually performed for assessment of the bony structures, image computation with an edge-enhancing algorithm (bone kernel) is important for the evaluation of axial source images (Fig. 8.5) and the postprocessing of multiplanar reconstruction images (see below). For 3D surface-shaded reconstructions and volume-rendering, calculation of a second dataset with middle kernel significantly improves image quality. The source planes acquired in the hand and the reconstructed planes, calculated afterwards, are compiled in Table 8.2.

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Image Postprocessing from CT Volume Datasets

Table 8.2 Acquisition planes and multiplanar reconstruction (MPR) in CT of the hand Region Examined

Acquired Plane

Reformatted Planes (MPR)

Distal section of forearm

Axial

Coronal and sagittal

Entire carpus

Axial

Coronal and sagittal

Scaphoid

Oblique-sagittal

Oblique–coronal

Metacarpal region

Sagittal

Coronal (and axial if necessary)

Finger

Sagittal

Coronal (and axial if necessary)

Image Postprocessing from CT Volume Datasets Multiplanar Reconstruction (MPR) In this reconstruction method, which is frequently used for all clinical objectives regarding the hand, slices in any direction are calculated from the axial slab of images. Depending on the target region, the new image plane is planned on an axial reference image, and a reconstruction slab of images aligned in parallel is determined. The newly calculated images generally have a slice thickness of one voxel and contain the densities of all pixels in the slice plane. The following basic diagnostic process has proved useful for calculation of MPR slices to achieve standardized reconstruction planes. U If there is no (sub)luxation in the distal radioulnar joint, the coronal MPR slices in the distal section of the forearm run parallel to the centers of the cross-sections of the radius and ulna. U The calculation of coronal MPR images from an axial dataset of the wrist is anatomically precisely planned when the planigraphic block runs parallel to a connecting line between the palmar sides of the distal pole of the scaphoid and the pisiform (Fig. 8.4 a and 8.6). The planigraphic block must then be moved with this angulation into the desired reconstruction region. U The planning of sagittal MPR images is preferably done on a coronal MPR slice that has already been calculated. The sagittal planigraphic block is positioned perpendicularly on this slice (Fig. 8.7). U The oblique-sagittal reconstruction parallel to the longitudinal axis of the scaphoid is planned on coronal images and aligned according to the shape of the scaphoid (Fig. 8.4 b). U For special clinical objectives, the reconstruction plane is aligned to the anatomic structure of interest.

Three-dimensional Surface Reconstruction The shaded-surface-display reconstruction (SSD) displays an object in three dimensions on the basis of a defined density threshold. In the preparatory segmentation, a density threshold is determined (e.g., 180–320 HU for reconstruction of a bone) below which all pixels are

excluded and only pixels above this value are used for image calculation. The segmentation also consistently includes an image filter for reduction of interfering pixels (“flying pixels”) left over from image noise after threshold assignment in the reconstruction volumes. The result is a view of the object whose visual impression can be strengthened by the perspective play of light and shadow (Fig. 8.9). The three-dimensional object can be arbitrarily rotated in space and observed from all directions. SSD reconstruction of the hand is used in complex fractures for survey presentation of the fragments and their dislocation(s). In surface reconstruction of the skeleton of the hand, individual bony elements can be electronically removed (exarticulated) when parts of the joint overlap, thereby providing an uninterrupted view of

a

b Fig. 8.4 a, b Planning MPR slices. a The coronal MPR plane is aligned on an axial slice so that it runs parallel to the palmar borders of the scaphoid and pisiform. b The oblique-sagittal MPR plane is aligned longitudinally to the scaphoid on a coronal MPR slice.

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Lister’s tubercle

sigmoid notch

head of the ulna

a

scaphoid

lunate

triquetrum

head of the capitate

Fig. 8.5 a–d Normal carpal anatomy in axial CT source images. a Through the distal radioulnar joint. b Through the proximal carpal row at the level of the head of the capitate. c At the transition of the two carpal rows. d Through the distal carpal row.

pisiform

b scaphoid

capitate

triquetrum

trapezium

tip of the hamate pisiform c

trapezoid

metacarpal I

hamate

capitate

d

Fig. 8.6 a, b Normal carpal anatomy in coronal MPR images. a Through the middle of the carpus. b Through the palmar section of the carpal tunnel.

hook of the hamate

carpal tunnel trapezium

pisiform

scaphoid b

a

capitate

metacarpal II

hamate

trapezoid

hook of hamate

lunate trapezium

triquetrum

lunate

pisiform

scaphoid radius

radius a

ulna

radius

b

c

Fig. 8.7 a–d Normal carpal anatomy in sagittal MPR images. a Through the scaphoid and the scaphotrapeziotrapezoid joints. b Through the lunate. c At the level of the hook of the hamate. d At the level of the pisotriquetral joint.

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d

Image Postprocessing from CT Volume Datasets

trapezium

metacarpal I

trapezium

trapezoid

scaphoid

scaphoid d

radius a

radius b

c

e Fig. 8.8 a–f CT anatomy of the scaphoid. a, b Oblique-sagittal slices in the longitudinal extension of the scaphoid, including the trapezium and the trapezoid. c Three-dimensional image of the scaphoid with the adjacent scaphotrapeziotrapezoid and carpometacarpal joints, as well as the trapezium and trapezoid. View of the concave joint surface to fit the head of the capitate, which, like the rest of the carpal bones, has been electronically removed. d, e, f Three-dimensional presentation of the electronically exarticulated scaphoid: d dorsal view, e proximal view, and f radial view. f

the entire joint (Fig. 8.8 c). The object to be removed is discriminated from the surrounding anatomical structures according to its density. This process can be simplified by electronically removing a superficial layer of pixels (“erosion”) and the image harmonized by adding pixels (“dilatation”).

These volume-rendered images can impressively demonstrate the complex anatomy of the hand. Because of the complexity of segmenting and editing involved in volume rendering, this procedure is not practical in routine diagnostic CT of the hand.

Maximal Intensity Projection (MIP) Volume Rendering (VR) Rotatable three-dimensional images can also be achieved with this procedure, not only on the basis of a defined density value but also on the basis of volumes and surfaces using density values of all pixels relevant to the image. The tissues of interest are assigned the parameters “CT density interval” and “transparency.” For example, color-coded tendons and blood vessels can be superimposed in three-dimensions onto the bones of the hand.

Mostly arteriograms from CT datasets of the hand are provided with this method. Only pixels with the highest density values along a projection beam through the image dataset are selected and projected onto a virtual image. Following bolus injection of contrast medium, the maximal density values represent the lumina of blood vessels. The MIP images can then be rotated arbitrarily in the spatial planes.

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a Palmar view.

b Dorsal view. Note the vascular canal in the lunate.

Fig. 8.9 a–c Three-dimensional views of the carpus in surface-shaded display (SSD) mode. c

Proximal view.

Normal Anatomy with Evaluation of the Slice Planes Nearly isotropic voxels can be acquired from the hand with multislice spiral CT. Assigning pixel magnitudes to these voxels makes it possible to compute an image in all spatial planes in the multiplanar reconstruction (MPR) process. If slices of submillimeter thickness are acquired, the MPR images produced secondarily from the volume dataset are almost equivalent to the original axial images in appearance and diagnostic value. Through the possibilities offered by multiplanar image reconstruction, the multislice technique has revo-

lutionized CT of the hand at the level of data acquisition and postprocessing, as well as at the level of diagnostic potential. The dataset acquired by means of the multislice technique supplies high-resolution images of the bony structure in the three spatial dimensions. The most important slice planes in CT imaging of the hand are defined anatomically in Table 8.3, which can serve as a reference for the two-dimensional reconstruction planes relevant to clinical indications.

CT Arthrography Multislice spiral CT opens up new possibilities in multiplanar evaluation of nonosseous lesions of the hand. Clinical questions concerning the intrinsic ligaments (scapholunate and lunotriquetral ligaments), the ulnocarpal complex (triangular fibrocartilage complex, TFCC), and the articular cartilage can be answered (see Fig. 8.10).

Technical Procedure The first step involves performing conventional arthrography under fluoroscopic control. Three-compartment arthrography with administration of contrast medium into the radiocarpal and midcarpal joints and the distal

radioulnar joint is generally performed. Intercompartmental communications reduce the number of punctures necessary. The technical procedure is described in Chapter 3. For CT arthrography alone, a contrast medium concentration of 150 mg I/ml suffices. Spot films taken under fluoroscopic control are obligatory. Postarthrographic CT is performed immediately after arthrography. Acquisition of axial slices 0.5–0.75 mm thick is recommended when using the multislice CT technique. The other film parameters are FoV 60–80 mm, pitch factor 1.3, tube voltage 120kV at a current–time product of about 200mAs, increment of 0.3 for a slice thickness of 0.5mm and increment of 0.5 for a slice thickness of 0.75. Coronal MPR is the most important

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CT Arthrography

Table 8.3 Preferred 2D planes in CT of the hand Anatomic Structure

Plane of First Choice

Plane of Second Choice

Radius

Sagittal

Coronal

Ulna

Coronal

Sagittal

Distal radioulnar joint

Axial

Coronal

Radiocarpal joint

Sagittal

Coronal

Scaphoid

Oblique-sagittal

Oblique-coronal

Trapezium, trapezoid

Oblique-sagittal

Oblique-coronal

Lunate

Sagittal

Coronal

Triquetrum

Coronal

Sagittal

Capitate

Coronal

Sagittal

Pisotriquetral joint

Axial

Sagittal

Hamate

Axial

Coronal

Hook of the hamate

Axial

Sagittal

Midcarpal joint

Coronal

Sagittal

Carpometacarpal joint I

Oblique-coronal

Oblique-sagittal

Metacarpals

Sagittal

Coronal

Metacarpophalangeal joints

Sagittal

Coronal

Phalanges

Sagittal

Coronal

Interphalangeal joints

Sagittal

Coronal

technique for assessment of the intrinsic ligaments and the ulnocarpal complex; reconstruction in the three orthogonal spatial planes is used for analysis of the articular cartilage. Radial reconstructions with a center in the styloid process of the ulna are necessary for assessment of peripheral lesions of the TFCC.

Interpretation and Clinical Applicability The spaces enclosed by intra-articular contrast agents are assessed in CT arthrography (Fig. 8.10): U The scapholunate and lunotriquetral ligaments appear as linear gaps in the contrast medium. U The triangular fibrocartilage (TFC) appears as a nearly biconcave void between the radius and the styloid process of the ulna.

LT lig.

TFCC a

U

The articular cartilage appears as an approximately 1 mm-wide void in the contrast medium running parallel to the cortical osseous layer covering the joint.

CT arthrography offers diagnostic advantages over MR arthrography for the above-named structures because of its higher spatial resolution (image matrix 512 × 512, slice thickness of 0.5 mm) in the assessment of the size/density, continuity, and surface character. In contrast, CT arthrography offers no information concerning the inner architecture of the joint structures surrounded by contrast medium since the density values are not very specific. A recent study comparing CT and MR arthrography revealed identical findings for lesions of the intrinsic ligaments and the TFCC.

LT lig.

SL lig.

SL lig.

TFCC b

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Fig. 8.10 a, b CT arthrography of a central perforation of the scapholunate ligament. In a middle MPR slice (a) the ligament is dehiscent, whereas in the palmar view (b) the ligament is continuous. Note that the articular cartilage is also left blank in the contrast filling of the CT arthrography. LT lig. = lunotriquetral ligament; SL lig. = scapholunate ligament; TFCC = triangular fibrocartilage complex.

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Osteoabsorptiometry The degree of ossification of the subchondral bone plate correlates directly with the axial pressure load on the joint. Accordingly, increased load–as in osteoarthritis– leads to an increase in osteosclerosis and therefore to increased bone density in joints. CT offers the possibility of quantifying subchondral bone density.

Technical Procedure A three-dimensional CT dataset of the radiocarpal joint, which is axially acquired with thin slices, serves as a basis. In segmentation steps, the carpal bones are electronically removed from the forearm, and the remaining radius and ulna are reconstructed in the three-dimensional surface mode. From this model, a slice from the subchrondral bone is cut out and, finally, the extra-articular compact bone is removed. The cumulative bone density of this slice of radius (and ulna) is measured and values are grouped into density intervals of 100 HU each.

Fig. 8.11 Osteoabsorptiometry. Density values are color coded in the segmented 3D slice of the distal radius and ulna sections (here in b/w mode).

The intervals of bone density are assigned false colors topographically representing load ratings on the joint (Fig. 8.11). Special software tools are available for taking osteoabsorptiometric measurements.

Table 8.4 Indications for CT of the hand U

U

U

U

U

U

U

Fractures of the distal section of the forearm – Staging the intra-articular radius fracture – Restaging malunion of a radius fracture Restricted movements of forearm rotation – Malrotation after radius fracture – Static/dynamic instability in the distal radioulnar joint – Initial osteoarthritis in the distal radioulnar joint Scaphoid fracture – Evidence of a radiologically occult fracture (compare with MRI) – Staging the extent of a fracture – Follow-up of the degree of consolidation Nonunion of the scaphoid – Determination of form and internal structure of the fragments – Assessment of scaphoid/periscaphoid joint surfaces Complex carpal trauma – Identification of all fractures and (sub)luxations – Determination of the extent of all dislocations and luxations – Classification of the trauma pattern Special traumas of the carpus – Dorsal avulsion from triquetrum suspected – Pisotriquetral impaction suspected – Fracture of the hook of the hamate suspected Metacarpal trauma – Injury to the carpometacarpal transition suspected – Complex Rolando’s fracture – Comminuted fracture of a metacarpal head

U

U

U

U

U

U

Trauma to a finger – Dislocated fracture of a phalangeal condyle – Severely impacted fracture of a phalangeal base Osteonecrosis of the lunate (Kienböck disease) – Classification of the internal bony structure of stages II–IIIa – Detection of initial stages of osteoarthritis Axial articular load and osteoarthritis – Osseous density distribution of the subchrondral bony plate – Identification of initial stages of osteoarthritis – Assessment of joint surface in therapy planning of partial fusion of the carpus – Articular loose bodies suspected Osteomyelitis – Identification of the extent of bone destruction – Identification of sequesters and sequester osteomyelitis – Exclusion of inflammatory joint involvement Tumorous bony lesions – Identification of an intraosseous ganglion – Impending fracture due to cystic bone tumor suspected – Identification of nidus in suspected osteoid osteoma – Osseous staging of suspected malignant bone tumor Soft-tissue diseases – Acute calcium hydroxyapatite deposition suspected – Calcium pyrophosphate dihydrate deposition (chondrocalcinosis) suspected – Staging of soft-tissue tumor when MRI is contraindicated

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Indications

Interpretation and Clinical Applicability Density analysis of the articular bones provides direct information about joint load. For the radiocarpal joint, for instance, it can be demonstrated whether pressure is primarily transmitted through the radial carpal column, and thereby through the fossa scaphoidea radii, or through the middle column and the fossa lunata radii, or whether an intermediate load distribution is involved. Further-

more, the dorsopalmar site of maximal density can provide information regarding the functional center of the joint in articular imbalances of carpal structures. In rotational subluxation of the scaphoid, the point of maximal bone density in the fossa scaphoidea radii is displaced toward the dorsal lip of the radius. A definitive assessment of osteoabsorptiometry of the wrist has not yet been performed.

Indications Computed tomography can provide additional diagnostic information about the hand in the indications for the disease entities listed in Table 8.4, which shows that highresolution CT using thin-slices is the method of choice for visualization of ossified bony structures. The main indications for CT of the hand are in traumatology and degenerative joint diseases.

Further Reading Adani R, Calò M, Torricelli P, Squarzina PB, Caroli A. The value of computed tomography in the diagnosis of soft-tissue swellings of the hand. J Hand Surg. 1990;15B:229–232. Bain GI, Bennett JD, Richards RS, Slethaug GP, Roth JH. Longitudinal computed tomography of the scaphoid: A new technique. Skeletal Radiol. 1995;24:271–273. Biondetti PR, Vannier MW, Gilula LA, Knapp R. Wrist: Coronal and transaxial CT scanning. Radiology. 1987;163:149–151. Blum A, Bresler F, Voche P, Merle M, Regent D. CT-arthrography of the wrist. In: Gilula and Yin, eds. Imaging of the Wrist and Hand. Philadelphia, Pa: Saunders; 1996:384–400. Bush CH, Gillespy T, Dell PC. High-resolution CT of the wrist: Initial experience with scaphoid disorders and surgical fusions. Am J Roentgenol. 1987;149:757–760. Canovas F, Roussanne Y, Captier G, Bonnel F. Study of carpal bone morphology and position in three dimensions by image analysis from computed tomography scans of the wrist. Surg Radiol Anat. 2004;26:186–190. Cone RO, Szabo R, Resnick D, Gelberman R, Taleisnik J, Gilula LA. Computed tomography of the normal soft tissue of the wrist. Invest Radiol. 1983;18:546–551. Farber JM. Imaging of the wrist with multichannel CT. Semin Musculoskelet Radiol. 2004;8:167–173. Fiedler E, Schmitt R, Fellner F, Bautz W. Terminology collection of radiologic concepts of modern sectional imaging methods of the hand. [in German] Handchir Mikrochir Plast Chir. 1998;30: 272–280. Frahm R, Mannerfelt L, Drescher E. Indications for computerized tomography of the wrist joint and carpal bones. [in German] Handchir Mikrochir Plast Chir. 1989;21:189–194. Frahm R, Saul O, Drescher E. CT diagnosis of malalignment following distal radius fracture. [in German] Radiologe. 1989;29:68–72. Frahm R, Lowka K, Wimmer B. Computed tomography of the wrist. [in German] Radiologe. 1990;30:366–372. Friedman L, Yong-Hing K, Johnston GH. Forty degree angled coronal CT scanning of scaphoid fractures through plaster and fiberglass casts. J Comput Assist Tomogr. 1989;13:1101–1104. Friedman L, Yong-Hing K, Johnston GH. Use of coronal computed tomography in the evaluation of Kienböck’s disease. Clin Radiol. 1991;44:56–59.

Giunta R, Löwer N, Kierse R, Wilhelm K, Müller-Gerbl M. Stress on the radiocarpal joint. CT studies of subchondral bone density in vivo. [in German] Handchir Mikrochir Plast Chir. 1997;29:32–37. Gupta A, Al Moosawi NM, Agarwal RP. In vivo CT study of carpal axial alignment. Surg Radiol Anat. 2003;25:455–461. Hauser H, Rheiner P, Gajisin S. Computertomographie der Hand. Röntgenstr. 1984;51:26–37. Hindman BW, Kulik WJ, Lee G, Avolio RE. Occult fractures of the carpals and metacarpals: Demonstration by CT. Am J Roentgenol. 1989;153:529–532. Jessurun W, Hillen B, Zonneveld F, Huffstadt AJG, Beks JWF, Oberbeck W. Anatomical relations in the carpal tunnel: A computed tomographic study. J Hand Surg. 1987;12B:64–67. Kalender WA. Computertomographie. Grundlagen, Gerätetechnologie, Bildqualität, Anwendungen. Munich: Wiley VCH Verlag GmbH; 2000. King GJ, McMurty RY, Rubenstein JD, Ogston NG. Computerized tomography of the distal radioulnar joint: Correlation with ligamentous pathology in a cadaveric model. J Hand Surg. 1986; 11A:711–717. Kiuru MJ, Haapamaki VV, Koivikko MP, Koskinen SK. Wrist injuries; diagnosis with multidetector CT. Emerg Radiol. 2004;10:182–185. Klein HM, Vrsalovic V, Balas R, Neugebauer F. Imaging diagnostics of the wrist: MRI and Arthrography/Arthro-CT. [in German] Fortschr Röntgenstr. 2002;174:177–182. Magid D, Thompson JS, Fishman EK. Computed tomography of the hand and wrist. Hand Clin. 1991;7:219–233. Merhar GL, Clark RA, Schneider HJ, Stern PJ. High-resolution computed tomography of the wrist in patients with carpal tunnel syndrome. Skeletal Radiol. 1986;15:549–552. Mino DE, Palmer AK, Levinsohn EM. The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radioulnar joint. J Hand Surg. 1983;8A:23–31. Muren C, Nygren E, Svartengren G. Computed tomography of the scaphoid in the longitudinal axis of the bone. Acta Radiol. 1990;31: 110–111. Patel RB. Evaluation of complex carpal trauma: Thin-section direct longitudinal computed tomography scanning through a plaster cast. J Comput Tomogr. 1985;9:107–109. Pennes DR, Jonsson K, Buckwalter KA. Direct coronal CT of the scaphoid bone. Radiology. 1989;171:870–871. Pirela-Cruz MA, Goll SR, Klug M, Windler D. Stress computed tomography analysis of the distal radioulnar joint: A diagnostic tool for determining translational motion. J Hand Surg. 1991;16A:75–82. Preißer P, Buck-Gramcko D. Computerized tomography of the hand with high resolution technique. [in German] Handchir Mikrochir Plast Chir. 1992;24:136–144. Quinn SF, Murray W, Watkins T, Kloss J. CT for determining the results of treatment of fractures of the wrist. Am J Roentgenol. 1987;149: 109–111. Quinn SF, Belsole RS, Greene TL, Rayhack JM. Advanced imaging of the wrist. Radiographics. 1989;9:229–246.

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Quinn SF, Belsole RS, Greene TL, Rayhack JM. Postarthrography computed tomography of the wrist: Evaluation of the triangular fibrocartilage complex. Skeletal Radiol. 1989;17:565–569. Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg. 1988;13A:182–187. Schmid MR, Schertler T, Pfirrmann CW et al. Interosseous ligament tears of the wrist: Comparison of multi-detector row CT arthrography and MR imaging. Radiology. 2005;237:1008–1013. Schmitt R, Lucas D, Buhmann S, Lanz U, Schindler G. Computed tomographic findings in carpal tunnel syndrome. [in German] Fortschr Röntgenstr. 1988;149:280–285. Schmitt R, Lanz U, Lucas D, Warmuth-Metz M, Schindler G. Computerized tomography of the hand: examination technic, normal anatomy, indications. [in German] Handchir Mikrochir Plast Chir. 1989; 21:89–96. Sim E, Zechner W. Computerized tomography after surgical management of scaphoid fractures and pseudarthroses with implants in

place. Method and results in 15 cases. [in German] Handchir Mikrochir Plast Chir. 1991;23:67–73. Stewart NR, Gilula LA. CT of the wrist: A tailored approach. Radiology. 1992;183:13–20. Viegas SF, Patterson RM, Todd PD, McCarty P. Three-dimensional computed tomography imaging: Its applicability in the evaluation of extensor tendons in the hand and wrist. J Comput Assist Tomogr. 2005;29:94–98. Viegas SF, Patterson RM, Todd PD, McCarty P. Measurement of carpal bone geometry by computer analysis of three dimensional CT images. J Hand Surg. 1993;18A:341–349. Weeks PM, Vannier MW, Stevens WG, Gilula LA. Three dimensional imaging of the wrist. J Hand Surg. 1985;10:32–39. Wegener OH. Ganzkörpercomputertomographie. 2nd ed. Berlin: Blackwell Wissenschaft; 1992. Zucker-Pinchoff B, Hermann G, Srinivasan R. Computed tomography of the carpal tunnel: A radioanatomical study. J Comput Assist Tomogr. 1981;5:525–528.

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Magnetic Resonance Imaging F. Fellner, R. Schmitt

Magnetic resonance (MR) imaging is the method of choice for identifying diseases of the bone marrow, articular cartilage, synovium, ligaments, and other soft tissues of the hand. Spin-echo (SE) and gradientecho (GRE) sequences are applied. Only the use of dedicated coils and the intravenous application of contrast medium ensure optimal image quality and high diagnostic reliability. MR arthrography is a special technique for detection of abnormal intra-articular processes. Important indications for MRI are di-

seases associated with trauma (fractures, ruptured ligaments, and lesions of the triangular fibrocartilage complex [TFCC]), inflammatory and tumorous diseases of the synovium, osteonecroses, and tumors of the soft tissues and bones. Apart from projection radiography, contrast-enhanced MRI is the most important technique used in hand imaging, with the exception of computed tomography (CT) for evaluating bony lesions.

MR Imaging Basics If a patient is placed in a magnetic field, the spins of the atomic nuclei arrange themselves in this external magnetic field according to certain principles. One relates to “thermal equilibrium.” Excitation with radiofrequency (RF) energy, which is set to a particular frequency to achieve the resonance requirements, disturbs this equilibrium (the excitation process). After the source of RF energy is turned off, the system returns to equilibrium, and the body emits the supplied energy in the form of RF waves (the relaxation process). This energy is taken up by antennas (coils), and the signal is passed on for computer processing. For spatial encoding, additional spatially and temporally changeable magnetic fields (gradient fields), which are superimposed on the main magnetic field in

the three spatial dimensions, are needed. Gray-scale images are calculated by special mathematical algorithms. Changing the sequence and measurement parameters (e.g., excitation and refocusing pulses, gradient switching, repetition time [TR], and echo time [TE], inversion time [TI]), creates different image contrasts. The timing of RF pulses and gradient switching is determined by the acquisition parameters of different pulse sequences. Only the nuclei of hydrogen-1 (1H)—i.e., protons—are used for routine diagnostic imaging of the hand in MRI. Excitation of other nuclei—e.g., sodium, potassium, fluorine—is of no importance in evaluating the hand.

Table 9.1 Most important pulse sequences in MRI of the hand

Pulse Sequences

SE Sequences

The sequence types listed in Table 9.1 are used in modern MRI systems. One of the first sequences used in MRI was the SE sequence. This was soon followed by different GRE sequences for routine imaging, as they considerably shortened the acquisition time. Fast imaging techniques, like turbo spin-echo (TSE) or fast spin-echo (FSE), further have been developed in attempts to reduce the measurement time.

GRE Sequences

Conventional spinecho

SE

Conventional gradient echo

GRE

Fast spin-echo (turbo spin-echo)

FSE, TSE

Fast gradient echo

Various acronyms

(Turbo)Inversion recovery

(T)IR

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Spin-Echo Technique Depending on the repetition time (TR) and echo time (TE), spin-echo (SE) sequences can provide information about the tissue relaxation times T1 (longitudinal relaxation time) and T2 (transverse relaxation time) and thereby create different image contrasts. A 90° excitation pulse rotates the longitudinal magnetization 90° into the transverse plane. At the same time, the spins are synchronized so that they are in phase. After turning off the excitation pulse, the transverse magnetization decreases according to the T2* decay, and the spins begin to precess at different frequencies again. This is due to the magnetic influence of their surroundings–inhomogeneity of the magnetic field caused by surrounding tissue and imperfection of the magnet. Halfway through the echo time, a 180° refocusing pulse is applied, and inverts the spin 180° in the transverse plane, bringing the fast spins behind the slow spins. Since the spins maintain their speed and direction of rotation, the fast spins begin to catch up with the slow ones. The signal reaches its maximum at the echo time TE. This is when the signal is registered. The 180° refocusing pulse rephases only those spins that were out of phase because of the inhomogeneity of the applied magnetic field. The spins that are out of phase because of the tissue-dependent spin–spin interaction (T2 relaxation) are not affected, so that the contrast of the different tissues is determined by the tissue-dependent relaxation times. To determine the origin of the acquired signals, several interactions using magnetic field gradients are required: U Simultaneous application of the 90° excitation pulse and the slice-selection gradient Gs results in excitation of a given slice. U Then the phase-encoding gradient G is activated, ph which conducts one of the phase encoding steps per TR cycle. U After half the echo time, the 180° refocusing pulse is applied, and the slice-selection gradient is switched on simultaneously. The signal is read at the echo time TE. At precisely that time, the readout gradient Gr is activated. The pulse-sequence diagram for an SE sequence is shown in Fig. 9.1. By choosing appropriate values for TR and TE, different types of contrast, so-called MRI weighting, can be achieved. U Choosing very short values for TR and TE (e.g., 600/ 15 msec) results in a T1-weighted contrast. This contrast is determined primarily by the different T1 rela-

U

U

xation times. Spins in tissues with a longer T1 relaxation time cannot relax sufficiently between two excitation pulses and, therefore, do not contribute to the signal. Substances such as water appear hypointense in T1-weighted images. T2 relaxation effects are largely suppressed by the short TE. If, in contrast, a long TR and a long TE are chosen (e.g., 3000/90 msec), the result is a T2-weighted contrast. Since the spins can relax almost completely between two excitations, the signal is almost independent of T1 relaxation. Tissues with longer T2 relaxation times, like water, appear hyperintense. If a long TR and a short TE are selected (e.g., 2200/ 17 msec), contrast is largely independent of the relaxation times T1 and T2. The resulting contrast is mainly determined by the proton density.

The conventional spin-echo technique is a standard method of acquisition of T1-weighted images. Because of decreased T1 contrast and a certain amount of blurring, fast spin-echo sequences should not be used for T1weighted imaging of the small parts of the hand.

Fast Spin-Echo Technique Fast SE sequences are differentiated from conventional SE sequences in that several differently phase-encoded echoes are read out within a TR cycle. The echo train length (ETL) indicates the number of echoes acquired per TR cycle. The higher the echo train length, the shorter the scan time. For clinical use, echo train lengths between 3 and approximately 30 have proved useful. The FSE technique is shown in Fig. 9.2. In spite of a contrast behavior very similar to that of the SE technique, FSE sequences display some special contrast characteristics. An obvious difference is the hyperintense representation of fatty tissue in T2weighted images. With the FSE technique T1-weighted, proton-density- (PD-)weighted, and T2-weighted images can be obtained. This technique can also be used for inversionrecovery sequences. With regard to T2-weighting, the FSE sequences have replaced conventional SE sequences. In evaluation of the joints and bones of the hand, the PD-weighted FSE sequence with spectral fat saturation is useful. Not only can it identify an edematous pattern in bone marrow, but it also provides information concerning the articular cartilage. In our experience, PD FSE sequences can replace the hitherto more frequently applied STIR (short T1 inversion recovery) sequence for most clinical objectives in imaging of the hand.

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Pulse Sequences

Inversion Recovery Technique Inversion recovery (IR) sequences provide excellent contrast behavior for T1- and T2-weighted images. The IR technique additionally makes possible the acquisition of fat-saturated images, the so-called STIR sequence. It is largely identical to the SE technique, with a 180° inversion pulse added at the beginning of each TR cycle. The time from the initial 180° inversion pulse to the following 90° excitation pulse is referred to as the inversion time (TI). If the inversion time is chosen so that the longitudinal magnetization Mz of a tissue is zero, when the 90° pulse is applied this tissue cannot be excited because it is “saturated.” It is therefore displayed as hypointense in the corresponding images. In the STIR technique, the TI is chosen so that the longitudinal magnetization of the fat is zero (fat saturation). In the FLAIR (fluid-attenuated inversion recovery) technique, the longitudinal magnetization of water is zero (water saturation). The IR technique is shown in Fig. 9.3. A disadvantage of these sequences is the long scan time, which can exceed that of SE sequences. For this reason, IR sequences are usually performed in the turbo technique.

90°

180°

IR sequences are rarely used in hand imaging. Only the T2-weighted STIR sequence is of importance, because its fat-suppressing ability facilitates identification of lesions containing increased fluid. However, the STIR sequence is less specific than spectral fat saturation, so the STIR technique should be used only as an alternative when spectral fat saturation provides no qualitatively satisfactory results. Since the STIR sequence can cause extinction of contrast -medium enhancement, it must not be performed after administration of a positive contrast agent.

Gradient-Echo Technique Gradient-echo (GRE) sequences considerably shorten scan times. They have the following characteristics (Fig. 9.4): U A flip angle ¥ less than 90° can be chosen. U The flip angle ¥ influences image contrast, as does the choice of TR and TE. U The echo is produced through inversion of the readout gradient before the signal readout; 180° refocusing pulses, like those used in the SE technique, therefore are not needed.

90°

90°

RF

t

Gs

180°

180°

180°

RF

t

t

Gs

t

Gph

t

Gph

t

Gr

t

Gr

t

S

t

S

t

TE effective echo time TEeff echo distance

TR

Fig. 9.2 Diagram of a fast (turbo) spin-echo sequence (FSE or TSE).

Fig. 9.1 Diagram of a spin-echo (SE) sequence.

180°

90°

180°

α°

180° t

TI Mz

TE Mx,y

α°

RF

t

Gs

t

Gph

t

Gr

t

S

t

TR

Mo t – Mo

Fig. 9.3 RF pulses and magnetization in an IR sequence.

Fig. 9.4 Principle of a gradient-echo (GRE) sequence.

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GRE sequences do not depend only on T2 effects but primarily rely on T2* decay–i.e., on T2 relaxation and the inhomogeneity of the magnetic field. For this reason, GRE sequences are highly sensitive to fluctuations in magnetic susceptibility and, therefore, to the presence of metal implants and calcifications. The specific absorption rate is significantly lower because there is no 180° refocusing pulse. Shorter times for TR and TE can be selected, thereby reducing scan times. The following types of GRE sequences are differentiated according to their sequence designs.

GRE Sequences with Dephasing of the Transverse Magnetization The following sequences are, in principle, similar, but have different vendor-dependent acronyms: FLASH, T1FFE, or Spoiled GRASS. In the FLASH sequence, at the end of a repetition cycle the phase coherence of the transverse magnetization is destroyed by a “spoiler” before the next excitation. A spoiler gradient or a suitable switching of RF pulses can serve as a spoiler and make it possible to begin quickly with the next excitation. Neither the T1 nor the T2 relaxation is complete because of the short repetition time. Using a flip angle of less than 90° reduces the signal, but with a short TR sufficient spins remain for a new excitation. Depending on the choice of the parameters TR, TE, and ¥, T1-weighted, PD-weighted, and T2*-weighted images can be created. Fast T1-weighted, three-dimensional (3D) FLASH sequences are the basis of contrast-enhanced MR angiography sequences. T2*-weighted FLASH sequences in axial orientation are highly suitable for differentiation of tendons from their sheaths and, in coronal orientation, for imaging of intrinsic ligaments, as well as the components of the triangular fibrocartilage complex. No indications for T1-weighted GRE sequences of the hand have been identified.

GRE Sequences with Rephasing of the Transverse Magnetization An example of a refocused GRE sequence is the FISP (fast imaging with steady precession) sequence (with the synonyms FFE [fast field echo] and GRASS [gradient-recalled acquisition in a steady state]). In contrast to the FLASH sequence, the transverse magnetization is not dephased but is rephased through inversion of the phase-encoding gradient. MR angiography. FISP sequences are the basis for 3D time-of-flight (TOF) sequences. Compared with contrastenhanced angiography sequences, 3D TOF sequences

offer the advantage of higher spatial resolution. They are usually employed before administration of contrast medium.

GRE Sequences of Special Design DESS Sequence The DESS (dual echo steady state) technique is a doubleecho, 3D GRE sequence. In the mixed sequence, two echoes with different contrasts, i.e., GRE echoes of the FISP and PSIF (reversed FISP) types, are acquired within one TR cycle. Although the PSIF part of the image is strongly T2-weighted, the FISP part of the image provides a T1/T2* contrast. The signal-to-noise ratio is very good in the DESS sequence, and multiplanar reconstruction (MPR) from the nearly isotropic 3D dataset is also possible. Articular cartilage of medium signal intensity can easily be differentiated from joint effusion of high signal intensity with the DESS sequence. The main indication is, therefore, identification of cartilaginous lesions. If no joint effusion is present, imaging of the surface of articular cartilage is best done with MR arthrography.

MEDIC Sequence This is a T2*-weighted GRE sequence in multiecho technique (MEDIC = multiecho data image combination). Using a FLASH sequence with flow-compensation, several echoes with different T2 weighting are collected in each TR cycle and then combined into an image. The advantages of the MEDIC sequence are a good signal-to-noise ratio, comparatively few chemical-shift artifacts, and good T2* contrast. Initial experience has shown that the MEDIC sequence is suitable for diagnosis of cartilage abnormalities in the hand.

CISS Sequence The CISS (constructive interference in the steady state) sequence is a 3D GRE sequence with strong T2* contrast. The CISS sequence unites two differently constructed true-FISP sequence parts. The CISS sequence is used primarily for diagnosis of central nervous system abnormalities. In an experimental study, this sequence proved to be very well suited for imaging of the bony structures of the hand. At present, however, use of the CISS sequence is not a standard technique for diagnostic imaging of musculoskeletal structures.

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Pulse Sequences

a

b

c

d

e

f

Fig. 9.5 a–f Contrast -medium effects in posttraumatic MRI studies, demonstrated on scapholunate dissociations in three different patients. a, b Focal contrast enhancement at the ruptured site of the ligament after intravenous administration of contrast medium with obvious improvement in the visualization of the lesion. Plain T1weighted SE sequence (a) and fat-saturated after application of contrast medium (b). c, d Direct MR arthrography. T1weighted SE sequence postarthrographically. Evidence of a partial rupture of the scapholunate (SL) ligament and type 1a lesion of the triangular fibrocartilage. e, f Indirect arthrography. Although the SL ligament is only faintly recognizable in the plain T1-weighted SE sequence (e), indirect MR arthrography with a fat-saturated T1-weighted SE sequence (f) displays the SL ligament clearly.

VIBE Sequence The VIBE (volumetric interpolated breath-hold examination) sequence is a dedicated 3D gradient-recalled-echo sequence. VIBE allows the volume acquisition with thin partition slices in a reasonable time due to a Fourier interpolation algorithm for symmetrically not measured phase-encoding steps in the k-space periphery. By reducing the flip angle from 12° to 15°, the VIBE sequence delivers an excellent T1 contrast. Therefore, the technique can be applied in contrast-enhanced imaging with spectral fat-saturation, as initially shown in dynamic MRI studies of the abdomen and pelvis. However, in our experience, the VIBE sequence is very useful also in 3D imaging of the wrist, particularly for depicting small intraarticular lesions with contrast-enhanced T1weighted images of 0.5 mm thickness.

Fast and Ultrafast GRE Sequences Fast GRE sequences, known by the names turbo-FLASH, turbo-field echo (TFE), or fast SPGR, can reduce scan times

to seconds. These sequences are mainly used for dynamic contrast-enhanced studies in which the image quality is less important than short scan times. Ultrafast gradient-echo sequences are echo-planarimaging sequences (EPI), which enable scanning to be performed within fractions of seconds. They are used primarily in neuro-MRI with diffusion, perfusion, and functional techniques.

Three-dimensional Technique (3D Technique) In the 3D technique, an entire volume (“slab” or “chunk”) is excited, instead of a block of slices as in the 2D technique. An advantage of volume excitation is the excellent signal-to-noise ratio. With a 3D dataset slices with minimal partition thicknesses of 0.4 mm can be acquired. For routine examinations, slice thicknesses of 1 mm are generally sufficient. Since the entire volume of the examined object is initially excited, the individual partitions must

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Table 9.2 Indications for 3D GRE sequences in MRI evaluation of the hand 3D Sequence

Structures Displayed

T1-weighted 3D GRE U With spectral fat saturation

Articular cartilage

T2*- and T1/T2*-weighted 3D DESS U With spectral fat saturation, or U With water excitation

Articular cartilage

T2*-weighted 3D MEDIC

Articular cartilage and bone marrow

T2*-weighted 3D GRE

Carpal ligaments and TFCC

T1-weighted 3D GRE U Without spectral fat saturation, or U With spectral fat saturation

Arterial and venous blood vessels

be encoded in slice-selection direction by an additional phase-encoding gradient. No gaps between the slices occur with volume excitation. A disadvantage of the 3D techniques is the relatively long scan time, and for that reason volume acquisition is useful only with GRE sequences. After data acquisition, postprocessing may be necessary and can be time-consuming. The following methods are available for postprocessing of 3D datasets: U Slices in any desired orientation, not only orthogonally aligned but also oblique or curved reconstruction slices, can be calculated from a 3D dataset by means of multiplanar reconstruction (MPR). U In MR angiographic techniques, the vessel lumen generally contains the pixels with the highest signal intensity. In the case of maximum intensity projection (MIP) only the pixels with the highest signal intensity are taken into consideration for calculation of pseudothree-dimensional projections.

If a fixed threshold for the signal intensity is defined in image segmentation, it is possible to display the surface of the object of interest with a three-dimensional appearance from the 3D dataset (surface-shaded display [SSD]). U In volume rendering (VR) different signal intensities are correlated to defined opacity values. This procedure thus uses the information from the dataset more effectively than in the previously-mentioned techniques. Volume rendering provides high-quality three-dimensional images. Three-dimensional techniques are used in diagnosis of the articular cartilage and the ligaments of the hand with the sequences shown in Table 9.2. Ultrafast GRE sequences are not routinely used for diagnostic imaging of the hand. U

Fat-Saturation Techniques Four different forms of fat saturation are available: U Spectral fat saturation: By selective excitation before the actual imaging procedures, the fatty tissue is selectively saturated and thereafter has reduced signal intensity. Since this technique requires a very homogenous magnetic field, it is very sensitive to artifacts and leads to inhomogeneous fat saturation if this condition is not fulfilled. U Short T1 inversion recovery (STIR): This is, in contrast to the spectral technique, a robust fat-saturation procedure that nearly always provides homogeneous fat saturation. However, it is less specific than spectral fat saturation. It can also lead to saturation of other substances when their T1 relaxation curves pass zero on the ordinate at the same time as the fatty tissue. This also applies to contrast-enhancing structures, which is why STIR sequences must not be used after adminis-

tration of gadolinium. The STIR sequence cannot provide a diagnostically useful display of cartilage.

Table 9.3 Fat-saturation techniques Fat-saturation Technique

Diagnostic Utility

Spectral fat saturation

Method of choice

Short TI inversion recovery (STIR)

Alternative if quality of spectral fat-saturation is insufficient

Gradient-echo T2* “out of phase”

Differentiation between red bone marrow and pathological bone marrow

Water excitation

Possible alternative to spectral fat-saturation; clinical value not yet clarified

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Contrast Medium

U

For diagnosis of the hand, spectral fat saturation is preferable to the STIR technique. The STIR technique should be used only as an alternative when spectral fat saturation is not successful. The GRE sequence in phase and out of phase: The Larmor proton spin-precession frequencies of fat and water differ only minimally. This effect leads to a “chemical shift.” Fat and water spins are brought into phase in SE sequences by the 180° pulse at the echo time. In GRE sequences, the phases of fat and water spins depend on the echo time, since the 180° pulse is missing in this type of sequence. In this case, there are echo times in which the spins of fat and water molecules are in or out of phase. The signal behavior changes accordingly.

U

This sequence type is used in MRI of the abdomen. In the musculoskeletal system, the opposed-phase technique has hitherto been used only in the evaluation of changes in the bone marrow, whereby T2*-weighted opposed-phase GRE sequences can distinguish red bone marrow from abnormal bone marrow infiltrations. Water excitation: In this technique the fatty tissue is not selectively saturated by RF pulses, but the water spins are selectively excited. As a result the water excitation acts as an indirect form of fat saturation. The value of this method remains to be evaluated in musculoskeletal MRI.

The applications and diagnostic value of the fat-saturation techniques described above are shown in Table 9.3.

Parallel Imaging Parallel imaging is a technique to shorten scan times that is applied together with array coils. The basic idea underlying parallel imaging is that different coil elements or receiving channels of an array coil record different parts of the k-space. The spatially different sensitivity profiles of the individual coil elements are exploited. To obtain artifact-free images, the missing k-space lines must be appropriately completed. This completion can take place in the k-space, as well as in the spatial domain. SMASH (simultaneous acquisition of special harmonics) and

GRAPPA (generalized autocalibrating partially parallel acquisition), for example, are methods that function in k-space, while SENSE (sensitivity encoding) works in the spatial domain. The advantage of parallel imaging is the shortening of scan time without loss of spatial resolution. This procedure does, however, reduce the signal-to-noise ratio. Besides shortening scan time, reduction of artifacts in EPI sequences is another important application of parallel imaging techniques.

Contrast Medium Contrast Medium Effects In contrast-enhanced MRI, positive and negative contrast agents are distinguished. Positive contrast agents: As paramagnetic substances, these lead to signal increase of enhancing tissue in T1weighted sequences. Since the magnetic moment of an electron shell with unpaired electrons is stronger than that of an atomic nucleus with unpaired nucleons, only substances with unpaired electrons are used as contrast agents. Gadolinium (Gd), a metal from the lanthanide group that has strong paramagnetic characteristics due to its seven unpaired electrons in half-filled 4f orbit, is most often used. In unbound form it is toxic, but this toxicity is canceled by chelate formation with DTPA or other ligands. Good contrast can be achieved with a dose of 0.1 mmol/kg body weight of gadolinium. The most important gadolinium-based contrast agents are listed in Table 9.4.

The second positive contrast agent, manganese (Mn) in the form of manganese-DPDP chelate, is of no importance in diagnosis of the musculoskeletal system. The working principle behind paramagnetic contrast agents is a change in the relaxation times of protons that are located near the molecules of contrast agent. This leads to a reduction in relaxation times T1 and T2. Because the reduction in T1 is greater than that in T2, T1weighted sequences are generally acquired after administration of contrast medium. Intravenous application of contrast medium improves the contrast differences of all enhancing lesions in comparison to surrounding tissue. Two further effects can be observed in the musculoskeletal system. An intense synovial enhancement in the joints, tendon sheaths, and bursae is characteristic in the presence of synovitis. At the site of a traumatic lesion, focal enhancement occurs within the fibrovascular regenerative tissue. This enhancement can be seen about one day after the trauma in enhanced MRI and can provide decisive diagnostic information (Fig. 9.5 a, b).

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Table 9.4 Gadolinium-based contrast agents for MRI examination (according to Tombach) Generic Name

Trade Name

Relaxivity* (mmol–1 × s–1)

Concentration (mmol ml 1)

Gadopentate dimeglumine

Magnevist

4.8

0.5

Gadoteridol

ProHance

4.9

0.5

Gadodiamide

Omniscan

4.4

0.5

Gadobenate dimeglumine

MultiHance

9.7

0.5

Gadobutrol

Gadovist

5.6

1.0

(*measured at 0.47 Tesla in blood plasma)

Negative contrast agents: These contrast agents, based on iron oxides, decrease signal intensity in T2-weighted images. One differentiates between superparamagnetic iron oxides (SPIO) and ultrasmall superparamagnetic iron oxides (USPIO). Iron oxides are preferred for diagnosis of the liver. Their value in diagnosis of bone marrow changes is currently under investigation.

Contrast Medium Administration for Standard Investigations For standard two-dimensional (2D) imaging, a positive gadolinium-containing contrast medium is manually injected into a cubital vein via an indwelling cannula. The minimum dose for contrast medium with standard relaxivity is 0.1 mmol/kg body weight. Higher contrast can be achieved with 0.2 mmol/kg body weight (double dose). When contrast agents with a higher relaxivity or higher concentration (Multihance, Gadovist) are used, the dose can be halved.

Contrast-Enhanced MR Angiography A 3D GRE sequence (FLASH) dataset is acquired during arterial passage of an intravenously administered bolus of contrast medium through the volume to be examined. The contrast agent is administered mechanically according to defined injection parameters with a dual-head power injector followed by a saline flush. A preinjection dataset is recorded using the same parameters. Following contrast-medium injection, the postcontrast dataset is subtracted from the precontrast dataset (filling image minus mask image). Angiographic images are computed from the subtracted dataset by maximum intensity projection (MIP).

In MR angiography of the arteries of the hand and fingers, which is described in detail in Chapter 5, a highresolution examination technique is distinguished from a time-resolved technique. U High-resolution 3D MR angiography is performed with partitions of 1.0–1.5 mm slice thickness. The goal is to achieve nearly isotropic voxels for diagnosis of the metacarpal and finger arteries. Since scan time is between 25 and 30 seconds, exact timing of the contrast bolus with a test bolus or under fluoroscopic control is necessary. After image subtraction, MIP reconstructions in all orientations are possible. U In time-resolved 3D MR angiography, partition thicknesses of 8 mm are used. Five coronal partitions are scanned, and the result is a reduction in scan time of 3–5 seconds. If ten contiguous phases are acquired, the scan delay following contrast medium injection can be set to approximately 15 seconds. The time-resolved technique is recommended for the vessels of the forearm as far as and including the palmar arch. MIP reconstruction remains limited to the coronal acquisition plane.

MR Arthrography The goal of MR arthrographic techniques is the differentiation of intra-articular structures achieved by improved surrounding contrast and distension of the structures in question by contrast medium. Two procedures are available: U Direct MR arthrography: Diluted gadolinium solution is injected directly into the radiocarpal and midcarpal joint compartments and/or the distal radioulnar joint under sterile conditions. Because contrast medium is applied under fluoroscopic control, the solution consists of a mixture of x-ray and MR contrast media in a ratio of 200:1, respectively. One-, two-, and threecompartment techniques are differentiated according to the target region and the distribution of contrast agent. The MR arthrographic examination with the sequence protocol described in Table 9.11 is performed immediately after radiologic arthrography (Fig. 9.5 c, d). Technical details of the examination are described in Chapter 10. U Indirect MR arthrography: In an indirect procedure the gadolinium-containing contrast medium is injected into the vein, and the patient is instructed to move his or her hand intensively for approxiamately 20 minutes. Such movements cause the contrast medium to diffuse into the joint space via the synovium. The result is contrast enhancement around intra-articular structures (Fig. 9.5 e, f ). The effect is weaker than that of direct MR arthrography because the joint contains significantly less contrast agent and, therefore, the joint structures are less distended.

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Planning of the Examination Volume

Nephrogenic Systemic Fibrosis (NSF) As known so far, NSF is a systemic disorder that occurs only in people with kidney disease. In this patient group, specific triggers for the development of NSF are assumed, particularly the exposure to gadolinium-containing MRI contrast agents. Besides impaired renal function, NSF may be associated with coagulation abnormalities, deep venous thrombosis, recent vascular surgery, and angioplasty procedures. Patients suffering from NSF develop large areas of hardened skin with dermal plaques and confluent papules, predominantly on the extremities, resulting in

reduced range of joint motion and contractures. Histologically, there are numerous fibroblasts and collagen bundles in the NSF skin lesions. Although gadoliniuminduced pathogenesis of NSF is not proven, recent studies have verified the deposition of gadolinium molecules in the tissue of NSF patients, while other research suggests an association with simultaneous acidosis. Actually, the FDA recommends not using gadolinium-containing contrast agents in patients with a decreased glomerular filtration rate (GFR) of 30 mL/min or less, and to use a single gadolinium dose of 0.1 mmol/kg body weight only. NSF has not been observed in association with modern MRI contrast agents like gadobentate (Multihance) and gadobutrol (Gadovist).

Dynamic MR Imaging of the Carpus The goal of dynamic MRI is to achieve temporal resolution of carpal movements. For real-time imaging, highfield scanners with a high-gradient capability are required. Optimal hardware and software performance can provide movement studies with a repetition frequency of one image per second and a matrix size of 128 × 128. The images are then displayed electronically in a cine loop for evaluation. State-of-the-art technology still has diagnostic limitations. The carpal ligaments are either not visualized or

not sufficiently visualized because of the reduced image matrix. Also, the frame speed is generally too low for recognition of temporary movement disturbances. As a result, dynamic MRI currently has no advantages over cineradiography. Because of the lack of temporal resolution, high-resolution image sequences acquired under static conditions in different wrist positions and afterwards made into a movie have no real diagnostic use.

Planning of the Examination Volume In-center and off-center hand positions are demonstrated in Fig. 9.6. To achieve reproducible slice orientation, applying a standardized procedure in planning images (so-called “localizers” or “scouts”) is important. Double angulations may lead to acquisition of oblique orientations, which make image interpretation difficult. A simple method of

achieving orthogonal slices, independently of the position of the hand, is described below: Step 1: Acquisition of axial scouts. Step 2: Acquisition of sagittal scouts perpendicular to the plane connecting the radius with the ulna (perpendicular to the imagined course of the interosseous membrane).

Fig. 9.6 a, b Positioning of the hand for MRI examination. a Positioning of the hand “in center.” The patient lies prone and elevates the arm above his or her head. The hand is in pronation (superman’s position). b Positioning the hand next to the body (“off center”). The patient lies supine with the hand in neutral position. a

b

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Table 9.5 Recommendations for MRI sequences of hand imaging Parameter

Clinical Objective

Type of Sequence

Orientation

PD-/T2-/T2*weighting

Bone marrow edema

PDw FSE fs (alternative: STIR)

Coronal

Differentiation between tendon and tendon sheath

T2*w GRE

Axial

Ligaments and TFCC

T2*w GRE

Coronal

Articular cartilage

PDw FSE fs

Coronal and sagittal

Soft-tissue tumors

T2w FSE

Axial

Standard sequence for T1-weighting

T1w SE

Coronal

Articular cartilage

T1w 3D GRE fs

Coronal

Contrast-enhanced MRA

T1w 3D GRE fs

Coronal

Double-echo GRE sequence

Articular cartilage

3D DESS we

Coronal

Contrast medium

Intravenously for all clinical objectives

T1w SE plain and T1w SE fs after contrast-medium administration

Coronal (standard), transverse, sagittal

Intra-articularly for lesions of ligaments, the triangular fibrocartilage complex, and articular cartilage

T1w SE fs (optional after intraveneous administration of contrast medium) 3D DESS we

Coronal

T1 SE, T1 3D GRE

fs = spectral fat saturation; we = water excitation.

Step 3: Acquisition of coronal scouts perpendicular to a sagittal scout. The three scouts provide the anatomic basis for the further slice orientation. Acquisition is possible in a single scanning procedure with modern scanners (so-called triplane localizer). Step 4: Planning the axial images on the coronal scout. They are positioned perpendicular to the radius and ulna. Step 5: Planning of coronal images. For faster planning, coronal images can be positioned onto the axial scouts.

However, using the axial images acquired in Step 4 provides greater accuracy. In these, the coronal plane is anatomically correct if it is parallel to the connecting line between the palmar side of the distal scaphoid pole and the pisiform. The planigraphic block must then be placed at this angle in the center of the area to be examined. Step 6: Planning the sagittal images either perpendicular to the coronal scout in Step 3 or perpendicular to the middle coronal image in Step 5.

Recommendations for MR Imaging Sequences for Examining the Hand Recommendations based on the characteristics of the different sequences for diagnosis of abnormalities of the hand are given in Table 9.5.

Sequence Protocols In addition to a dedicated hand coil, MRI of the hand requires special protocols that guarantee high spatial resolution, as well as an adequate signal-to-noise ratio, in a small field of view (FoV). In our experience with 1.0 T and 1.5 T scanners, the following parameter settings are useful: U The FoV must be limited to 80–100 mm to achieve the necessary anatomic resolution of the carpus and fingers. The FoV can be increased to 120 mm for the metacarpus.

U

U

U

With a slice thickness of 3 mm, a matrix size of 256 × 512 (phase-coding direction × readout direction) is recommended; and with a slice thickness of 2 mm, a matrix size of 384 × 384. A rectangular FoV generally should not be selected for coronal orientation; for sagittal and axial orientations, however, a rectangular FoV of 50–70 % is suitable. To achieve a sufficient signal-to-noise ratio, the following number of acquisitions should be performed: two averages for T1-weighted SE; three averages for

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Sequence Protocols

PD-weighted FSE fs; three averages for T2-weighted FSE; two averages for T2*-weighted GRE; and one average for 3D DESS.

Basic MR Imaging Protocol (Table 9.6) The basic protocol for MRI is used for unspecific, clinically unclear complaints. A slice thickness of 3 mm is used to visualize the entire carpal volume.

MR Imaging Protocol in Carpal Trauma

MR Imaging Protocol in Scaphoid Trauma (Table 9.8) Because of its double-oblique alignment in standard planes, angulated slices running parallel to the anatomic longitudinal axis are necessary for diagnostic imaging of the scaphoid. Oblique-sagittal slices 2 mm thick with an FoV of 80 mm are suitable. T2-weighted sequences in coronal or sagittal orientation can identify traumatic bone marrow edema and serve as a basis for evaluation of carpal structures. Fat-saturated T1-weighted SE images following administration of contrast medium help to identify an accompanying injury of the carpal ligaments.

(Table 9.7) MRI is indicated for detection of a radiologically occult fracture of the distal section of the radius and/or the carpus. The protocol comprises T2-weighted sequences in coronal and sagittal orientation with which edema of the bone marrow caused by trauma can be recognized. After intravenous administration of contrast medium, the coronal, T1-weighted sequence demonstrates lesions of the ligaments and the triangular fibrocartilage complex by focal enhancement.

MR Imaging Protocol in Nonunion of the Scaphoid (Table 9.9) Osseous vitality is assessed indirectly by synoptic evaluation of the water content and perfusion of the bone marrow. Aside from the frequently occurring edema of the bone marrow, an important MRI characteristic in this case is the intensity and distribution of enhancement

Table 9.6 Basic protocol for MRI of the hand Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2*w GRE

Axial

3 mm/0 %

20

No

PDw FSE fs

Coronal

3 mm/0 %

12

No

T1w SE

Coronal

3 mm/0 %

12

No

T1w SE fs

Coronal

3 mm/0 %

12

Yes

T1w SE fs

Sagittal

3 mm/10–20 %

15

Yes

Table 9.7 MRI sequence protocol for acute carpal injuries Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2*w GRE

Axial

3 mm/0 %

20

No

PDw FSE fs

Coronal

3 mm/0 %

12

No

STIR or MEDIC

Sagittal

3 mm/10–20 %

15

No

T1w SE

Coronal

3 mm/0 %

12

No

T1w SE fs

Coronal

3 mm/0 %

12

Yes

Table 9.8 MRI sequence protocol for acute scaphoid injuries Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

PDw FSE fs

Coronal

3 mm/0 %

12

No

T2*w GRE or MEDIC

Sagittal

3 mm/10–20 %

15

No

T1w SE

Oblique-sagittal

2 mm/0 %

8

No

STIR

Oblique-sagittal

2 mm/0 %

8

No

T1w SE fs

Coronal

3 mm/0 %

12

Yes

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after intravenous administration of contrast medium. The T1-weighted SE slices are aligned parallel to the longitudinal axis of the scaphoid; the T2-weighted images are aligned in the coronal and sagittal planes.

MR Imaging Protocol in Lesions of the Ligaments and the Triangular Fibrocartilage Complex (Tables 9.10, 9.11) These lesions are caused by traumatic and degenerative changes. While structural disintegration in the avascular segments of tendons or disks can be recognized by inter-

spersed fluid, a focal contrast enhancement at the site of incipient fibrovascular repair in vascularized segments is diagnostically useful. Accordingly, both T2- and T1weighted sequences, as well as contrast-enhanced sequences, are used for diagnosis of ligament injuries. The coronal plane is preferable because of the course of the ligaments in the hand. MR arthrography should be used when a lesion in the avascular segment of the triangular fibrocartilage is suspected but this has not been visualized in T2weighted sequences, or when nonspecific contrast enhancement is seen in a ligament. It is advantageous to perform the MRI examination both with and without intravenous administration of contrast medium following fluoroscopically controlled arthrography.

Table 9.9 MRI sequence protocol for imaging of scaphoid nonunion Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

PDw FSE fs

Coronal

2 mm/0 %

12

No

T2*w GRE or MEDIC

Sagittal

3 mm/10–20 %

15

No

T1w SE

Oblique-sagittal

2 mm/0 %

8

No

T1w SE fs

Oblique-sagittal

2 mm/0 %

8

Yes

Table 9.10 MRI sequence protocol for tendons and the TFCC (no arthrograpy) Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2*w GRE

Axial

3 mm/0 %

20

No

PDw FSE fs

Coronal

2 mm/0 %

12

No

T1w SE

Coronal

2 mm/0 %

12

No

T1w SE fs

Coronal

2 mm/0 %

12

Yes

T1w SE fs

Sagittal

3 mm/10–20 %

15

Yes

Table 9.11 MRI sequence protocol for tendons and the TFCC (MR arthrography) Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

PDw FSE fs

Coronal

2 mm/0 %

12

No

T1w SE fs

Coronal

2 mm/0 %

12

No

T1w SE fs

Coronal

2 mm/0 %

12

Yes

T1w SE fs

Axial

3 mm/0 %

15

Yes

3D DESS we

Coronal

1 mm

40

Yes

Table 9.12 MRI sequence protocol for osteonecroses (lunate osteonecrosis) Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

PDw FSE fs

Coronal

2 mm/0 %

12

No

T1w SE

Coronal

2 mm/0 %

12

No

T1w SE

Sagittal

2 mm/0 %

12

No

T1w SE fs

Coronal

2 mm/0 %

12

Yes

T1w SE fs

Sagittal

2 mm/0 %

12

Yes

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Sequence Protocols

MR Imaging Protocol in Carpal Osteonecrosis (Lunate Osteonecrosis) (Table 9.12) Osteonecroses affect the lunate (Kienboeck disease), as well as the proximal fragment in scaphoid nonunion. A separate protocol is described for such cases. The osseous vitality can be evaluated indirectly according to the water content and perfusion of the bone marrow. The MRI parameter is, aside from edema of the bone marrow, the intensity and distribution of enhancement after intravenous administration of contrast medium. T1-weighted SE sequences with thin slices are acquired in coronal and sagittal planes both before and after administration of contrast medium. A T2-weighted FSE sequence is additionally performed in the coronal plane.

MR Imaging Protocol in Arthritic Joint Diseases

ing carpal arthritis. By reducing the slice thickness to 2 mm, this sequence recommendation can also be used to examine the metacarpophalangeal and proximal interphalangeal joints. The application of a gadolinium-containing contrast medium and performance of fat-suppression sequences are important in the examination of all inflammatory diseases of the synovium.

MR Imaging Protocol for Identification of Ganglia (Table 9.14) Ganglia are benign fluid-filled mass lesions on the dorsal or palmar side of the wrist that can be sensitively identified with T2-weighted sequences, preferably acquired in three orthogonal planes with different acquisition parameters. The stemlike connection to the synovial site of origin in a joint capsule or tendon sheath is often visualized only after venous application of contrast medium.

(Table 9.13) The commonest indication is undoubtedly rheumatoid arthritis, and the program shown is optimized for imag-

Table 9.13 MRI sequence protocol for rheumatoid arthritis of the carpus Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2*w GRE

Axial

3 mm/10–20 %

20

No

PDw FSE fs

Coronal

3 mm/0 %

12

No

T1w SE

Coronal

3 mm/0 %

12

No

T1w SE fs

Coronal

3 mm/0 %

12

Yes

T1w SE fs

Sagittal

3 mm/10–20 %

15

Yes

Table 9.14 MRI sequence protocol for ganglia Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2*w GRE

Axial

3 mm/0 %

20

No

T2*w GRE or MEDIC

Sagittal

3 mm/10–20 %

15

No

PDw FSE fs

Coronal

2 mm/0 %

12

No

T1w SE

Coronal

2 mm/0 %

12

No

T1w SE fs

Coronal

2 mm/0 %

12

Yes

Table 9.15 MRI sequence protocol for tumors of the bones and soft tissues Type of Sequence

Orientation

Slice Thickness/Gap

Number of Slices

Contrast Medium

T2w FSE (fs)

Coronal

3 mm/0 %

12

No

T1w SE

Coronal

3 mm/0 %

12

No

T1w SE fs

Coronal

3 mm/0 %

12

Yes

T1w SE fs

Sagittal

3 mm/10–20 %

15

Yes

T1w SE

Axial

3 mm/0 %

20

Yes

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MR Imaging Protocol for Diagnosis of Soft-tissue Tumors and Bone Tumors (Table 9.15) SE or FSE sequences are better suited for tissue characterization than GRE sequences are. To identify edema in

bone tumors, a T2-weighted FSE sequence with a spectral fat-saturation pulse is best. For soft tissues this examination should be conducted without fat saturation. After intravenous contrast -medium administration, T1weighted sequences are acquired in three orthogonal planes to reliably estimate the extent of any infiltration into the surrounding tissues.

Normal MR Anatomy of the Hand If images are acquired in pronation, as is the case when the patient is in prone position and the “in-center” technique is used, the following pitfalls must be taken into consideration. U In pronation, the ulnar head is physiologically located in the sigmoid notch of the radius in a discrete palmar position. Normally, the ulnar head is found in the distal radioulnar joint within a fan-shaped area bordered by the two lines that have been described by Mino (see Chapter 12), although the clinical impression may mimic a dorsal position of the ulna head. U In pronation, there is also a mild dorsal rotation of the lunate analogous to a “pseudo DISI” malalignment

(dorsiflexed intercalated segment instability, see Chapter 23). Under these circumstances, a rotation of the lunate up to 15° should not be mistaken for wrist instability.

Muscle Compartments and Neurovascular Bundles of the Forearm (Fig.9.7) In MRI topography the forearm can be divided into five muscular compartments and neurovascular bundles (Table 9.16). The interpretation is best made with axial MRI sequences.

extensor digitorum extensor carpi ulnaris extensor pollicis brevis abductor pollicis longus

extensor digiti minimi extensor pollicis longus extensor indicis

extensor carpi radialis brevis ulna radius

flexor carpi ulnaris

extensor carpi radialis longus ulnar artery ulnar nerve

pronator teres brachioradialis

flexor digitorum profundus flexor pollicis longus

median nerve flexor digitorum superficialis

anterior interosseous nerve anterior interosseous artery

palmaris longus flexor carpi radialis

Fig. 9.7 Normal MRI anatomy of the forearm. Axial T1-weighted SE slice at the level of the distal section of the forearm.

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Normal MR Anatomy of the Hand

Table 9.16 Muscle groups and neurovascular tracts of the forearm Muscle Groups

Muscle

Neurovascular Tract

Guiding Structure

Radial group

Brachioradialis

Radial neurovascular tract

Brachioradialis muscle Superficial branch of the radial nerve

Extensor carpi radialis longus Extensor carpi radialis brevis

Radial artery Superficial extensors

Extensor digitorum

Dorsal Interosseous tract

Extensor digitorum muscle Deep branch of the radial nerve

Extensor digiti minimi Extensor carpi ulnaris

Posterior interosseous artery Deep extensors

Abductor pollicis longus

Ulnar neurovascular tract

Extensor pollicis brevis Extensor pollicis longus Extensor indicis Supinator Superficial flexors

Deep flexors

Flexor carpi ulnaris

Middle neurovascular tract

Flexor carpi ulnaris muscle

Pronator teres

Ulnar nerve

Palmaris longus

Ulnar artery

Flexor carpi radialis

Flexor carpi radialis muscle

Flexor digitorum superficialis

Median nerve

Flexor digitorum profundus

Dorsal Interosseous tract

Anterior interosseous artery

Flexor pollicis longus Pronator quadratus

Osseous Structures of the Hand (Fig. 9.8) U

U

U

U

In MRI, the morphological assessment criteria of conventional radiography and CT imaging also apply for the distal forearm, the carpus, the metacarpus, and the fingers (Chapters 1, 8, and 12). As in the other skeletal regions, the ossified bony substance is visualized without signal in all sequences. In contrast, the bone marrow in T1- and T2-weighted SE and FSE sequences is displayed as hyperintense; it is slightly more intense in FSE sequences. When using GRE sequences, the signal intensity is intermediate and in this case is also dependent on the type of sequence and the flip angle. Normal bone marrow appears homogeneously hypointense in fat-suppressed sequences. Each signal enhancement denotes a pathologic condition of the bone or bone marrow. MRI is the method of choice for visualizing articular cartilage. With the sequences discussed here, articular cartilage has an intermediate signal intensity. In the

joints of the hand, the articular cartilage is only 1 mm thick and even less on the phalangeal joints. If there is no joint effusion, the space between the layers of cartilage of two joint partners appears as a fine, hypointense line. The preferred imaging plane for the articular cartilage of the distal radioulnar joint is the axial plane. For the cartilage of the radiocarpal and midcarpal joints, both the coronal and the sagittal planes should be used.

Carpal Ligaments and the Triangular Fibrocartilage Complex (TFCC) (Fig. 9.8 a) U

U

The preferred imaging plane for extrinsic and intrinsic ligaments, as well as for the triangular fibrocartilage complex, is the coronal orientation. The anatomy and diagnostic strategy of the complex system of carpal ligaments and the TFCC are discussed in Chapters 10 and 11.

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Lister’s tubercle

median nerve

lunotriquetral ligament meniscus homologue

b ulnar nerve pronator quadratus

triangular fibrocartilage complex scapholunate ligament a

palmar aponeurosis

tendon of flexor carpi radialis

dorsal intercarpal ligament

tendon of flexor digitorum superficialis

tendon of extensor digitorum

tendon of flexor digitorum profundus

radioscapholunate ligament

tendon of extensor indicis

palmar radioulnar ligament

radioscaphocapitate ligament

dorsal radiotriquetral ligament

radiolunate ligament

pronator quadratus d

c Fig. 9.8 a–d Normal MRI anatomy of the wrist. a Coronal PD-weighted FSE sequence with fat saturation. The intrinsic ligaments, the triangular fibrocartilage complex, and the articular cartilage are all well delineated. b Axial T2*-weighted GRE sequence through the distal radioulnar joint. Clear delineation of the articular cartilage with intermediate signal intensity from a hyperintense joint effusion.

Contents of the Carpal Tunnel (Fig. 9.9 a, b) U

The four tendons of the flexor digitorum superficialis muscle, the four tendons of the flexor digitorum profundus muscle, the tendon of the flexor pollicis longus muscle, and the median nerve all run through the carpal tunnel. Although the superficial and deep finger flexors II–V have a common tendon sheath, the flexor pollicis longus muscle has its own tendon sheath.

c Sagittal T1-weighted SE sequence at the level of the scaphoid. The trapezoid “rides” on the distal pole of the scaphoid. d Sagittal T1-weighted SE sequence at the level of the lunate. Note the collinear alignment of the radius, the lunate, the capitate, and the metacarpal III.

U

U

The tendons of the flexor digitorum superficialis (FDS) muscle are arranged into two groups, whereby tendons III and IV lie superficial to the tendons II and V. The fifth FDS tendon is usually very thin and hardly recognizable in cross-section. Sometimes it is even missing. The tendons of the flexor digitorum profundus muscle are grouped in the same way.

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Normal MR Anatomy of the Hand

U

U

U

U

In the carpal tunnel, the tendon of the flexor pollicis longus (FPL) muscle runs furthest to the radial side within a groove in the trapezium. It has its own tendon sheath. The tendons appear hypointense in all sequences. The so-called “magic-angle” effect is important: if a tendon runs at an angle of about 55° to the alignment of the external magnetic field, this causes signal enhancement within the tendon itself, especially in GRE sequences. This artifact must not be misinterpreted as tendinitis. The median nerve runs immediately below the flexor retinaculum on the palmar side inside the carpal tunnel. It is directly adjacent to the second FDS tendon and the FPL tendon. It has an intermediate or slightly hyperintense signal compared to muscle in all sequences. The tendon of the palmaris longus muscle, which maintains the tension of the palmar aponeurosis together with the palmaris brevis muscle, and the contents of Guyon’s canal run outside the carpal tunnel.

U

U

U

U

Guyon’s Canal (Fig. 9.9 a, b) U

U

Guyon’s canal, which is located superficially on the ulnar side of the carpus, is best assessed in axial slices. On the ulnar side it is bounded by the pisiform, the hook of the hamate, and the hypothenar muscles. On the dorsal side it is bounded by the flexor retinaculum and on the palmar side by the palmar carpal ligament. The contents of Guyon’s canal are, on the ulnar side, the ulnar nerve directly adjacent to the pisiform and, on the radial side, the ulnar artery and vein. The ulnar nerve divides into a superficial palmar branch and a deep palmar branch at variable levels within Guyon’s canal. Differentiation of the contents of Guyon’s canal is best done with a T1-weighted SE sequence.

U

U

U

The third extensor-tendon compartment contains the tendons of the extensor pollicis longus (EPL) muscle. Lister’s tubercle of the radius lies between the second and third extensor-tendon compartment. In its further course, the EPL tendon crosses the tendons of the extensor indicis muscle (fourth extensor-tendon compartment) and the ECRL and ECRB tendons (second extensor-tendon compartment). The fourth extensor-tendon compartment contains the tendons of the extensor digitorum (ED) muscle and the extensor indicis proprius (EIP) muscle. The fifth extensor-tendon compartment contains the tendon of the extensor digiti minimi (EDM) muscle. At the level of the triquetrum, the fifth extensor tendon follows a curved course to the ulnar side. The sixth extensor-tendon compartment contains the tendon of the extensor carpi ulnaris (ECU) muscle. This ECU tendon runs dorsal in its own tendon sheath in a groove in the ulnar head and inserts at the base of metacarpal V. In supination the ECU tendon can dislocate out of this groove, but physiologically not in pronation, which is the position used for MRI. Often a central signal not caused by the “magic angle effect” or tendinitis is seen in the tendon. The anatomical snuff-box (so-called “tabatière”), located dorsoradially at the wrist, is bounded by the tendons of the first extensor-tendon compartment (APL and EPB), as well as the tendon of the third extensortendon compartment (EPL). The radial artery, the ECRL tendon, and the scaphoid and trapezium are located at the base of the anatomical snuff-box. The extensor tendons of the fingers divide into a central and two collateral bands (syn.: slips) in the periphery. If they fill less than the entire circumference, small amounts of fluid in the extensor-tendon sheaths should be considered physiological in T2-weighted images.

Extensor Tendons (Fig. 9.9 a, d) The extensor apparatus is grouped into six tendon compartments, which are covered by the extensor retinaculum. The extensor tendons can be visualized well with T2*-weighted GRE sequences. U The first extensor-tendon compartment contains the tendons of the abductor pollicis longus (APL) muscle and the extensor pollicis brevis (EPB) muscle. U The second extensor-tendon compartment contains the tendons of the extensor carpi radialis longus (ECRL) muscle and the extensor carpi radialis brevis (ECRB) muscle.

The Thenar Region (Fig. 9.10 b) U

U

U

The thenar region contains the short thenar muscles, the radial artery, and the tendons of the flexor pollicis longus muscle, which can serve as anatomical guides. The short thenar muscles from the radial to the ulnar side are the abductor pollicis brevis muscle and opponens pollicis muscle, as well as the flexor pollicis brevis muscle and adductor pollicis muscle, both of which have two muscle bellies. The tendon of the flexor pollicis longus muscle is interposed between the two muscle bellies of the flexor pollicis brevis muscle.

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dorsal intercarpal ligament EPL

ECRB

ED, EI

EDM ECU

ECRL

EPB APL

FCU

FCR

a FPL

median nerve

arcuate ligament

b Guyon’s canal

FCR

radial artery

flexor retinaculum

ulnar nerve FDP FDS

ECRL ECRB ED, EI

EPL EPL

APL EPB

ECRL ECRB

c

d dorsal radiotriquetral ligament ED, EI EDM

Fig. 9.9 a–d Normal MR anatomy of the carpal tunnel and the flexor and extensor tendons. a In the axial T2*-weighted sequence, the six extensor-tendon compartments can be seen on the dorsal side. In the carpal tunnel, the tendons of the flexores digitorum superficialis et profundus muscles and the flexor pollicis longus muscle can be well differentiated from their tendon sheaths, as well as from the median nerve with intermediate signal intensity. Guyon’s canal lies superficially on the ulnar side.

b The coronal T1-weighted SE image shows the flexor tendons in the carpal tunnel and the ulnar nerve in Guyon’s canal. They are bounded on the radial side by the distal pole of the scaphoid and by the trapezium and on the ulnar side by the pisiform and the hook of the hamate. c, d Two adjacent coronal slices show the angulated course of the tendons of the extensor pollicis longus muscle (third extensor compartment) and the extensor digiti minimi muscle (fifth extensor compartment) on the dorsal side. See text for abbreviations.

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Normal MR Anatomy of the Hand

branch of median nerve

third lumbrical

tendon of flexor digitorum superficialis

a

abductor pollicis brevis

b

deep head of flexor pollicis brevis

opponens digiti minimi

opponens pollicis

tendon of flexor pollicis longus

deep head of flexor pollicis brevis

superficial head of flexor pollicis brevis

abductor digiti minimi

fourth dorsal interosseous

first dorsal interosseous

fourth palmar interosseous

oblique head of adductor pollicis

tendon of fifth flexor digitorum profundus

deep head of flexor pollicis brevis

tendon of fifth flexor digitorum superficialis

c branch of median nerve

third lumbrical

Fig. 9.10 a–c Normal MR anatomy of the metacarpus. a Coronal PD-weighted FSE sequence with fat-saturation through the middle of the palm of the hand. The tendons of the flexor digitorum profundus muscle with the adjacent lumbrical muscles on the radial side, as well as the tendon of the flexor pollicis longus muscle between the two bellies of the flexor pollicis brevis muscle, are visualized.

b Coronal, predominantly superficial slice through the thenar and hypothenar regions (plain T1-weighted SE sequence). The intrinsic thenar and hypothenar muscles can be differentiated. c Axial T1-weighted SE sequence at the level of the metacarpus. The tendons of the deep and superficial phalangeal flexors and the lumbrical muscles can be differentiated from one another, as well as from the interosseous muscles.

The Palmar Canal and the Metacarpus (Fig. 9.10 a, c) U

U

U

The middle palmar canal contains the tendons of all finger flexors, the lumbrical muscles, the superficial arterial palmar arch (at the middle metacarpal level), and the median nerve, which has already branched off into the digital palmar nerves at this point. The lumbrical muscles belong to the deep flexor tendons. These muscles originate at the radial edges of the deep flexor tendons and end on fingers II–V distal of the insertions of the interosseous muscles into the dorsal aponeurosis of the extensor apparatus. The two bellies of the adductor pollicis muscle can be seen running transversely in the layer below the flexor

U

tendons and lumbrical muscles, as well as the deep palmar arterial arch, which runs proximally at the level of the metacarpal bases. The interosseous muscles can be found in the interosseous spaces between the metacarpals. In axial and coronal T1-weighted SE images, the four thicker dorsal interosseous muscles can generally be well delineated from the three thinner palmar interosseous muscles. Like the lumbrical muscles, the interosseous muscles progress to the dorsal aponeurosis of the fingers and insert here proximally at the level of the metacarpophalangeal joints.

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IP joint

ulnar collateral ligament

palmar plate tendon of flexor pollicis longus

radial collateral ligament MP joint

superficial head of flexor pollicis brevis deep head of flexor pollicis brevis CMC joint first dorsal interosseous

STT joint a

b

Fig. 9.11 a, b Normal MRI anatomy of the thumb. a Coronal T1-weighted SE sequence. The collateral ligaments on the metacarpo-phalangeal joint have low signal intensity.

b Sagittal PD FSE with fat saturation. Note the high signal intensity of the articular cartilage and the low signal intensity of the palmar plate. lateral tract

intermediate tract

palmar plate

c

flexor digitorum superficialis tendon

flexor digitorum superficialis tendon

flexor digitorum profundus tendon

flexor digitorum profundus tendon

adductor pollicis

flexor digitorum superficialis tendon flexor digitorum profundus tendon tendon of extensor digitorum

a

b

Fig. 9.12 a–c Normal MR anatomy of a finger. a Sagittal T2*-weighted GRE sequence at the level of the metacarpus and the third proximal phalanx. The superficial and deep flexor tendons are well differentiated. b Sagittal T1-weighted SE sequence with visualization of the extensor tendon, including the dorsal aponeurosis and both flexor tendons.

c Axial slice at the level of the middle phalanx (T2*-weighted GRE sequence). Note the alignment of the deep and superficial phalangeal flexors and the central and collateral bands of the extensor apparatus. The blood vessels and nerves of the fingers are seen on the palmar-lateral sides, each.

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Normal MR Anatomy of the Hand

Hypothenar Region (Fig. 9.10 b) U

U

The hypothenar region contains the hypothenar muscles of the little finger, as well as the ulnar nerve and artery. From ulnar to radial, the hypothenar muscles of the little finger are the abductor digiti minimi muscle, the opponens digiti minimi muscle, and the flexor digiti minimi brevis muscle. The palmaris brevis muscle lies subcutaneously on the palmar side.

Thumbs and Fingers (Figs. 9.11 and 9.12) U

U

U

The tendons of the flexor digitorum superficialis muscle divide at the level of the proximal phalanges into a radial and an ulnar band, respectively. On each finger the tendon of the flexor digitorum profundus muscle runs between the two bands of the flexor digitorum superficialis muscle. The tendons of the flexor digitorum superficialis muscle insert at the middle phalanges. Those of the flexor digitorum profundus muscle insert at the distal phalanges. The dorsal aponeurosis (peripheral termination of the finger extensors) divides into a central and two collateral bands. The two collateral bands insert at the bases of the distal phalanges. The central band inserts at the middle phalanx. The collateral bands serve as insertion sites for the lumbrical and interosseous muscles.

Further Reading Alley MT, Shifrin RY, Pelc NJ, Herfkens RJ. Ultrafast contrast-enhanced three-dimensional MR angiography: State of the art. Radiographics. 1998;18:273–285. Beaulieu CF, Ladd AL. MR arthrography of the wrist: Scanning room injection of the radiocarpal joint based on clinical landmarks. Am J Roentgenol. 1998;170:606–608. Beltran J, Chandnani V, McGhee RA, Kursungoglu-Brahme S. Gadopentetate dimeglumine-enhanced MR imaging of the musculoskeletal system. Am J Roentgenol. 1991;156:457–466. Bergin D, Schweitzer ME. Indirect magnetic resonance arthrography. Skeletal Radiol. 2003;32:551–558. Blum A, Loeuille D, Lochum S, Kohlmann R, Grignon B, Coudane H. MR-Arthrography: General principles and applications. J Radiol. 2003;84:639–657. Boles CA, Kannam S, Cardwell AB. The forearm anatomy of the muscle compartments and nerves. Am J Roentgenol. 2000;174:151–159. Bonel H, Frick A, Sittek H et al. Examination of the hand and wrist joints with a dedicated low-field MRI device. [in German] Radiologe. 1997;37: 785–793. Brown RR, Clarke DW, Daffner RH. Is a mixture of gadolinium and iodinated contrast material safe during MR arthrography? Am J Roentgenol. 2000;175:1087–1090. Bruhn H, Gyngell ML, Hänicke W, Merboldt P, Frahm J. High-resolution fast low-angle shot magnetic resonance imaging of the normal hand. Skeletal Radiol. 1991;20:259–265. Cerezal L, Abascal F, Garcia-Valtuille R, Del Pinal F. Wrist MR arthrography: how, why, when. Radiol Clin North Am. 2005;43:709–31. De Maeseneer M, Van Roy P, Jacobson JA, Jamadar DA. Normal MR imaging findings of the midhand and fingers with anatomic correlation. Eur J Radiol. 2005;56:278–285.

Disler DG, Recht MP, McCauley TR. MR imaging of articular cartilage. Skeletal Radiol. 2000;29:367–377. Ehara S. Effect of MR imaging of the wrist on clinical diagnosis. Radiology. 2002;223:877. Elentuck D, Palmer WE. Direct magnetic resonance arthrography. Eur Radiol. 2004;14:1956–1967. Erickson SJ, Kneeland JB, Middleton WD et al. MR imaging of the finger: Correlation with anatomic sections. Am J Roentgenol. 1989; 152:1013–1019. Erickson SJ, Cox IH, Hyde JS, Carrera GF, Strandt JA, Estkowski LD. Effect of tendon orientation on MR imaging signal intensity: A manifestation of the »magic angle« phenomenon. Radiology. 1991; 181:389–392. Foo TKF, Shellock FG, Hayes CE, Schenck JF, Slayman BE. High-resolution MR Imaging of the wrist and eye with short TR, short TE, and partial-echo acquisition. Radiology. 1992;173:277–281. Fry ME, Jacoby RK, Hutton CW et al. High resolution magnetic resonance imaging of the interphalangeal joints of the hand. Skeletal Radiol. 1991;20:273–277. Guermazi A, Miaux Y, Zaim S, Peterfy CG, White D, Genant HK. Metallic artefacts in MR imaging: Effects of main field orientation and strength. Clin Radiol. 2003;58:322–328. Haims AH, Schweitzer ME, Morrison WB, Deely D, Lange RC, Osterman AL, Bednar JM, Taras JS, Culp RW. Internal derangement of the wrist: Indirect MR arthrography versus unenhanced MR imaging. Radiology. 2003;227:701–717. Hardy PA, Recht MP, Piraino D, Thomasson D. Optimization of a dual echo in the steady state (DESS) free-precession sequence for imaging cartilage. J Magn Reson Imaging. 1996;6:329–335. Hardy PA, Recht MP, Piraino D, Thomasson D. Pulley System in the fingers: Normal anatomy and simulated lesions in cadavers at MR imaging, CT and US with and without contrast material distension of the tendon sheath. Radiology. 2000;217:201–212. Hayman LA, Duncan G, Chiou-Tan F, Liu S, Taber KH. Sectional neuroanatomy of the upper limb III: Forearm and hand. J Compt Asst Tomogr. 2001;25:322–325. Hobby JL, Dixon AK, Bearcroft PW et al. MR imaging of the wrist: Effect on clinical diagnoses and patient care. Radiology. 2001:220: 589–593. Hodgson RJ, Barry MA, Carpenter TA, Hall LD, Hazleman BL, Tyler JA. Magnetic resonance imaging protocol optimization for evaluation of hyaline cartilage in the distal interphalangeal joint of fingers. Invest Radiol. 1995;30:522–531. Hopkins KL, Li KCP, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. 1995:24:325–330. Imhof H, Nobauer-Huhmann IM, Krestan C et al. MRI of the cartilage. Eur Radiol. 2002;12:2781–2793. Kett H, Prüll C. Physical principles and signal behaviour in magnetic resonance imaging. In: Breit A, ed. Magnetic Resonance in Oncology. Heidelberg: Springer; 1990:3–14. Kocharian A, Adkins MC, Amrami KK et al. Wrist: Improved MR imaging with optimized transmit-receive coil design. Radiology. 2002; 223:870–876. König H, Lucas D, Meissner R. The Wrist: A Preliminary Report on High-Resolution MR Imaging. Radiology. 1986;160:463–467. Krinsky G, Rofsky NM, Weinreb JC. Nonspecificity of short inversion time inversion recovery (STIR) as a technique of fat suppression: Pitfalls in image interpretation. Am J Roentgenol. 1996;166: 523–526. Lenk S, Ludescher B, Martirosan P, Schick F, Claussen C, Schlemmer HP. 3.0 T high-resolution MR imaging of carpal ligaments and TFCC. [in German] Fortschr Röntgenstr. 2004;176:664–667. Morrison WB. Indirect MR arthrography: Concepts and controversies. Semin Musculoskelet Radiol. 2005;9:125–134. Nikken JJ, Oei EH, Ginai AZ et al. Acute peripheral joint injury: Cost and effectiveness of low-field-strength MR imaging - results of randomized controlled trial. Radiology. 2005;236:958–967.

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Oneson SR, Scales LM, Erickson SJ, Timins ME. MR imaging of the painful wrist. Radiographics. 1996;16:997–1008. Partik B, Rand T, Pretterklieber ML, Voracek M, Hoermann M, Helbich TH. Patterns of gadopentetate-enhanced MR imaging of radiocarpal joints of healthy subjects. Am J Roentgenol. 2002;179: 193–197. Sahin G, Dogan BE, Demirtas M. Virtual MR arthroscopy of the wrist joint: A new intraarticular perspective. Skeletal Radiol. 2004;33: 9–14. Saupe N, Prussmann KP, Luechinger R, Bosiger P, Marincek B, Weishaupt D. MR imaging of the wrist: Comparison between 1.5- and 3-T MR imaging. Preliminary experience. Radiology. 2005;234: 256–264. Shellock FG. Functional assessment of the joints using kinematic magnetic resonance imaging. Semin Musculoskelet Radiol. 2003;7: 249–276. Schmidt HM, Lanz U. Surgical Anatomy of the Hand. Stuttgart: Thieme; 2004. Schmitt R, Christopoulos G, Meier R et al. Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients. [in German] Fortschr Röntgenstr. 2003;175:911–919. Schweitzer ME, Natale P, Winalski CS, Culp R. Indirect wrist MR arthrography: The effect of passive motion versus active exercise. Skeletal Radiol. 2000;29:10–14. Seymour R, White PG. Magnetic resonance imaging of the painful wrist. Br J Radiol. 1998;71:1303–1330. Stäbler A, Spieker A, Bonel H et al. MRI of the wrist: Comparison of high resolution pulse sequences and different fat suppression techniques. [in German] Fortschr Röntgenstr. 2000;172:168–174. Steinbach LS, Palmer WE, Schweither ME. Special focus session. MR arthrography. Radiographics. 2002;22:1223–1246. Theumann NH, Pfirrmann CW, Chung CB, Antonio GE, Trudell DJ, Resnick D. Pisotriquetral joint: assessment with MR imaging and MR arthrography. Radiology. 2002;222:763–770.

Tjin A, Ton ER, Pattynama PMT, Bloem JL, Obermann WR. Interosseous ligaments: Device for applying stress in wrist MR imaging. Radi-ology. 1995;196:863–864. Vahlensieck M, Peterfy CG, Wischer T et al. Indirect MR arthrography: Optimization and clinical indications. Radiology. 1996:200: 249–254. Vahlensieck M, Sommer T, Textor J et al. Indirect MR arthrography: Techniques and applications. Eur Radiol. 1998;8:232–235. Weiss KL, Beltran J, Shamam O, Stilla RF, Levey M. High-field MR surface coil imaging of the hand and wrist. I. Normal anatomy. Radiology. 1986;160:143–146. Winalski CS, Aliabadi P, Wright RJ, Shortkroff S, Sledge CB, Weissman BN. Enhancement of joint fluid with intravenously administered gadopentetate dimeglumine: Technique, rationale and implications. Radiology. 1993;187:179–185. Winterer JT, Scheffler K, Paul G et al. Optimization of contrastenhanced MR angiography of the hands with a timing bolus and elliptically reordered 3D pulse sequence. J Comput Assist Tomogr. 2000;24:903–908. Wong EC, Jesmanowicz A, Hyde JS. High resolution short echo time MR imaging of the fingers and wrist with a local gradient coil. Radiology. 1991;181:393–397. Yu JS, Habib PA. Normal MR imaging anatomy of the wrist and hand. Magn Reson Imaging Clin N Am. 2004;12:207–219. Zanetti M, Hodler J, Gilula LA. Assessment of dorsal or ventral intercalated segmental instability configurations of the wrist: Reliability of sagittal MR images. Radiology. 1998;206:339–345. Zlatkin MB,Greenan T. Magnetic resonance imaging of the wrist. Magn Res Quart. 1992;8:65–96.

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Anatomic and Functional Prerequisites for Diagnostic Imaging of the Hand 10 Carpal Ligaments

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Carpal Ligaments R. Schmitt

The carpal ligaments guarantee stability of the carpal joints while allowing considerable freedom of movement in these joints of complex construction. The interosseous and extrinsic ligaments, the proximal and the distal V-shaped ligaments on the palmar aspect, and the dorsal V-shaped ligaments can be distinguished from each other by their course. The

scapholunate and the lunotriquetral ligaments play an important role in carpal stability. For imaging of the carpal ligaments, radiographic arthrography preferably combined with CT or MRI, different types of MRI sequences, and arthroscopy are available. The diagnostic value of these procedures differs according to the individual ligaments.

Fundamental Anatomy Most of the carpal ligaments have an intracapsular course, but only a few reinforce the joint capsule. The palmar ligaments are thicker and functionally more important than the dorsal ligaments because of their stabilizing function. Carpal ligaments are classified in terms of their complex anatomic arrangement. The following description is based primarily on the functional V-shaped ligamentary system, which has been modified according to new information gained from MRI imaging (Table 10.1). The individual ligaments in this group are listed in Table 10.2. Their names derive from their origins and attachments, as well as from their directions. There are discrepancies in the literature regarding the precisely anatomically defined collateral ligaments. Since such ligaments, if they were robustly constructed, would restrict multiaxial movement in the wrist, only thin collateral supportive ligaments are found on the joint capsule. Nevertheless, the collateral ligaments in the wrist are listed in Table 10.1.

Radioscapholunate (RSL) Ligament, Radioscaphoid (RS) Ligament, and Radiolunate (RL) Ligament Current option is that the RSL ligament (Testut’s ligament), aside from stabilizing the proximal pole of the scaphoid, functions above all as a neurovascular bundle. The terminal branch of the anterior interosseous artery

LTL

Interosseous Ligaments Some of these ligaments have a membranous attachment to the articular cartilage, and some cross the cartilage and insert directly onto the bone as Sharpey’s fibers. The interosseous ligaments run in two directions, either taking a longitudinal course between the radius and the scaphoid and lunate or running transversely between the two carpal rows (Fig.10.1). The interosseous ligaments are the most important stabilizers of the carpus (unit of rotational stability).

SLL RSLL

Fig. 10.1 Diagram of the interosseous and intrinsic ligaments. The radioscapholunate ligament (RSLL), scapholunate ligament (SLL), and lunotriquetral (LTL) ligament are shown in red.

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Fundamental Anatomy

and a fiber from the anterior interosseous nerve are in this ligament. Both supply the scapholunate ligament and the proximal pole of the scaphoid. The RSL ligament originates at the palmar rim of the radius at the level of the interfacet prominence and extends with two fascicles to the palmar and middle sections of the scapholunate

ligament. The RSL ligament lies between the extrinsic RLT ligament in the palmar direction and the intrinsic SL ligament dorsally. The radioscaphoid and the radiolunate (“short radiolunate”) ligaments are not independent ligaments but delineated fascicles reinforcing the palmar joint capsule.

Table 10.1 Classification of carpal ligaments Principle of Classification

Group of Ligaments

Course of Ligaments

Direction of course

Extrinsic

Extend either from the forearm or from the metacarpus to the carpus: U U

Functional topography

on the palmar or dorsal aspect radiocarpal or ulnocarpal

Intrinsic

Extend intercarpal between the carpal bones

Interosseous

Extend deeply, directly between two bones

Palmar-proximal V

Converge as an “upside-down V” from the radius/ulna to the lunate

Palmar-distal V

Converge as an “upside-down V” from the radius/triquetrum to the capitate

Dorsal V

Converge as a “horizontal V” from the radius/scaphoid to the triquetrum

Table 10.2 Classification, position, and visibility of carpal ligaments (0 = not visible, + = visible over a short distance, ++ = visible over a long distance, +++ = completely visible) Ligament

Abbr.

Position

Arthroscopy

MRI

MRA

Interosseous U

Radioscapholunate

RSLL

Extrinsic

+++

+

++

U

Scapholunate

SLL

Intrinsic

+++

++

+++

U

Lunotriquetral

LTL

Intrinsic

+++

++

+++

U

Capitohamate

CHL

Intrinsic

+

++

++

Palmar proximal V U

Radiolunotriquetral

RLTL

Extrinsic

+

++

++

U

Ulnotriquetral

UTL

Extrinsic

++

+++

++

U

Ulnolunate

ULL

Extrinsic

++

+++

++

U

Triangular fibrocartilage

TFC

Extrinsic

+++

++

+++

Palmar distal V U

Radioscaphocapitate

RSCL

Extrinsic

++

+++

++

U

Scaphocapitate

SCL

Intrinsic

+

+

+

U

Arcuate (triquetrocapitoscaphoid)

TCSL

Intrinsic

+

+++

++

U

Scaphotrapeziotrapezoid

STTL

Intrinsic

+++

++

+++

Dorsal V U

Dorsal radiotriquetral

DRTL

Extrinsic

0

++

++

U

Dorsal intercarpal

DICL

Intrinsic

0

++

++

Collateral U

Radial collateral

RCL

Extrinsic

++

+

++

U

Ulnar collateral

UCL

Extrinsic

++

+

++

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dorsal dorsal

palmar volar

U

RSLL

Fig. 10.2 Diagram of the horseshoe-shaped construction of the scapholunate ligament. In the view from radial, one sees a palmar, a middle, and a strong dorsal segment of the ligament. Extending from proximal, the radioscapholunate ligament (RSLL) radiates into the palmar segment of the scapholunate ligament.

Topographically they are located on the radial and ulnar sides of the RSL ligament. The radiolunate ligament stabilizes the lunate in its course to the anterior horn, and the radioscaphoid ligament prevents the scaphoid from drifting dorsally. The interosseous ligaments of the proximal carpal row are clinically more important than those of the distal row.

U

palmar ligamentary segment. The palmar segment of this ligament is, like the radioscapholunate ligament which inserts here, surrounded by small blood vessels and nerve fibers and is relatively well vascularized. The middle segment of the SLL, which extends in the transverse plane, is a thin, fibrocartilaginous membrane without any stabilizing function. It extends between the articular cartilages of the scaphoid and the lunate. The middle, membranous third of the SL ligament is predisposed to degenerative perforations, which can regularly be found here from the 30th year of life and are referred to as “pinhole” defects. They are usually asymptomatic. During arthrography they can permit intercompartmental passage of contrast medium despite the absence of a scapholunate dissociation. The dorsal section, which can also be best seen in the coronal plane, comprises of thick, closely packed collagenous fibers running transversely. The major portion of these fibers insert via Sharpey’s fibers into cortical bone. The dorsal segment is surrounded by ultrafine blood vessels and nerve fibers. The thicker and relatively shorter dorsal section of the ligament ensures the actual stability of the scapholunate connection. Usually a traumatic injury (rarely a degenerative lesion) of the dorsal segment of the SLL causes rotation-subluxation of the scaphoid and scapholunate dissociation.

Scapholunate Ligament (SLL)

Lunotriquetral Ligament (LTL)

This very important ligament not only ensures close association between the scaphoid and lunate, but is also the most important stabilizer of the carpus. The SLL extends between the proximal borders of the scaphoid and the lunate. Because of the different joint circumferences of the scaphoid and the lunate as well as a certain intrinsic elasticity of the ligament, a relative rotational movement is possible between the scaphoid and lunate during flexion and extension. In the sagittal plane, the ligament stretches in a horseshoe shape at a depth of 13 mm and has an average total length of 18 mm (Fig.10.2). The SLL terminates distally with loose ends. Histologically, the SLL has three different segments with different biomechanical functions: U The palmar segment extends in a slightly obliquetransverse direction in the coronal plane. It consists of thick collagen fibers embedded in loose connective tissue and inserts directly into the cortical bone. This segment is longer than the other two. Because of this constellation, a slight movement between the scaphoid and the lunate is possible at the level of the

The lunotriquetral ligament is similar in construction to the SL ligament, but is thinner. As a tight ligament, it allows only a slight displacement between the lunate and the triquetrum from proximal to distal. The LTL is Ushaped. It consists of thinner dorsal and strong palmar fascicles that extend proximally in the coronal plane between the borders of the lunate and the triquetrum. The palmar segments of the ligament ensure functional stability between the two bones. They are supported by the palmar radiolunotriquetral ligament and the dorsal radiotriquetral ligament. The middle section of the LTL, which extends horizontally as a thin membrane, has no stabilizing function whatsoever. It is a preferred site for degenerative perforations.

Capitohamate Ligament (CHL) Thick interosseous ligaments of no particular clinical importance run between the bones in the distal carpal row. In MRI, the very stable CHL appears as a hypointense structure between the capitate and the hamate.

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Fundamental Anatomy

Palmar V-shaped Ligaments The palmar V-shaped ligaments are thicker than the dorsal ligaments. Within a complex anatomic arrangement, two V-shaped groups with the following ligaments can be differentiated according to functional aspects: U Ligaments of the palmar proximal “V”: radiolunotriquetral ligament (RLTL), ulnolunate ligament (ULL), and ulnotriquetral ligament (UTL) U Ligaments of the palmar distal “V”: radioscaphocapitate (RSCL) and arcuate (TCSL) ligaments Poirier’s space, an area largely free of ligaments, lies between the two groups of V-shaped ligaments on the palmar aspect at the level of the lunocapitate joint. Topographically, a row of ligaments on the radial side and another row on the ulnar side consist of: U Ligaments on the radial side: radioscaphocapitate ligament (RSCL) and radiolunotriquetral ligament (RLTL) U Ligaments on the ulnar side: ulnotriquetral ligament (UTL), ulnolunate ligament (ULL), and arcuate ligament (TCSL) The interosseous ligaments that are located furthest proximal (radioscapholunate ligament, radioscaphoid ligament, and radiolunate ligament) also lie on the palmar side. The carpal ligaments are described below according to the functionally oriented “concept of Vshaped ligaments.”

Ligaments of the “Proximal V” The function of the proximal set of ligaments with the radius and ulna functioning as the base and the lunate as the apex (Fig.10.3) is in the longitudinal transference of force between the ulna and the carpus and fixation of the proximal carpal row, especially the lunate as the intermediate element of movement (so-called “intercalated segment”).

Radiolunotriquetral Ligament (RLTL) The radiolunotriquetral ligament (also called the “long radiolunate ligament”) makes up the radial leg of the V and is the strongest carpal ligament. It originates with a broad base on the palmar rim of the radius and lies in ulnar and proximal proximity to the RSCL. It follows a relatively level course first to the lunate, where it attaches to its anterior horn with a few fibers, and continues in the same direction with thicker fascicles to terminate in a palmar trough on the triquetrum (Fig.10.3). Together with its dorsal “partner” ligament, the dorsal radiotriquetral ligament (DRTL), the RLTL performs the important function of preventing the carpus from slipping

UTL

RLTL

ULL

Fig. 10.3 Diagram of the palmar “proximal V” of the extrinsic ligaments. The proximal V-shaped group of ligaments comprises the radiolunotriquetral ligament (RLTL) on the radial side and the ulnolunate (ULL) and ulnotriquetral (UTL) ligaments on the ulnar side.

along the joint surface of the radius, which has a 25° inclination to the ulnar aspect. Because of their alignment with the ulnar inclination of the radial joint surface and their function of keeping the carpus in a stable position, the RLTL and DRTL ligaments are also known as the “extra-articular slingshot.”

Ulnolunate Ligament (ULL) and Ulnotriquetral Ligament (UTL) The ulnar leg of the proximal V consists of the palmar ligamentary structures of the triangular fibrocartilage complex (TFCC), i.e., the ulnolunate and the ulnotriquetral ligaments (Fig.10.3). Both ulnocarpal ligaments are located on the palmar aspect and fortify the triangular fibrocartilage complex. They originate on the palmar radioulnar ligament and proceed to the anterior horn of the lunate or to a depression on the palmar side of the triquetrum. Ligament fibers often radiate into the lunotriquetral ligament. The ULL and UTL are important stabilizers of the ulnar side of the carpus and prevent nondissociative forms of instability.

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Triangular Fibrocartilage Complex (TFCC) Aside from the ULL and the UTL, the triangular fibrocartilage complex also consists of the following elements: the triangular fibrocartilage (TFC), the palmar and dorsal radioulnar ligaments, the meniscus homologue, the tendon sheath of the extensor carpi ulnaris (ECU) muscle, and the ulnar collateral ligament. For details, see Chapter 11.

Ligaments of the “Distal V” The palmar distal V-shaped ligaments have an important function in stabilizing the midcarpal joint and in preventing the scaphoid from its tendency to rotate in a flexed position (Fig.10.4).

Radioscaphocapitate Ligament (RSCL) and Scaphocapitate Ligament (SCL)

rection (Fig.10.4). These sections lie distal to the RLTL. The RSCL originates with a broad base at the styloid process of the radius and extends in a diagonal direction on the palmar side first through the groove in the middle third of the scaphoid (“scaphoid waist”), from which it is separated by a synovial duplication. It then continues diagonally to insert on the palmar aspect of the middle part of the capitate. The distal half of the RSCL is accompanied by the SCL, which also connects the middle third of the scaphoid with the capitate. The ligamentary insertion prevents the capitate from drifting to the ulnar side. The RSCL keeps the scaphoid, which is aligned in a palmar direction, in a stable position and prevents it from tipping further toward the palmar aspect (“palmar support ligament”). If the scaphoid is fractured in the proximal half, the RSCL can fold into the fracture gap and lead to scaphoid nonunion.

Scaphotrapeziotrapezoid Ligament (STTL)

The radial side of the distal group of V-shaped ligaments consists of the radioscaphocapitate and the scaphocapitate ligament segments, which run in the same di-

In a wider sense of the term, the STTL must also be counted as a radial-distal leg of the V-shaped system of ligaments. These are intrinsic ligaments located on the palmar and dorsal sides that connect the scaphoid with the trapezium and the trapezoid as a “radial link” and permit only moderate movement among these three carpal bones.

Arcuate (Triquetrocapitoscaphoid) Ligament (TCSL)

TCSL

SCL RSCL

Fig. 10.4 Diagram of the palmar “distal V” of the extrinsic ligaments. On the radial side, the radioscaphocapitate ligament (RSCL) extends distally next to a fascicle of the scaphocapitate ligament (SCL). On the ulnar side, the arcuate ligament (TCSL) extends to the triquetral, capitate, and scaphoid.

The ulnar side of the distal group of V-shaped ligaments is formed by a ligament with an arching course, the arcuate ligament (so-called “delta ligament”). Because of its triquetrocapitoscaphoid course deep in the carpal tunnel, it will hereafter be referred to by the acronym TCSL. The ligament originates on the palmar side of the triquetrum, extends in a bow shape over the tip of the hamate and the neck of the capitate, and terminates on the palmar side of the distal third of the scaphoid (Fig.10.4). As a fairly loose ligamentary connection in the “ulnar link,” the TCSL permits the triquetrum to slide a considerable distance over the spiral-shaped joint surface of the hamate. This explains the “high” and “low” triquetral positions during radial and ulnar inclination. The rest of the TCSL is tighter and prevents palmar flexion of the proximal carpal row. The space between the proximal and distal fascicles of the palmar V-shaped ligamentary system at the level of the capitatolunate joint (Poirier’s space) has no ligaments and is filled with synovial tissue. The lack of a palmar lunocapitate ligament predisposes this space to become a “site of less resistance” in hyperextension traumas and explains the tendency of the lunate to dislocate to the palmar side in perilunate and lunate dislocations.

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Fundamental Anatomy

Ligaments of the “Dorsal V” Although the dorsal ligaments (Fig.10.5) are weaker than those on the palmar side, they are important biomechanically. Through their convergence at the triquetrum, the dorsal ligaments, together with the RLTL on the palmar side, which extends in the same direction, prevent the carpus from sliding along the radial joint surface, which slopes to the ulnar side (so-called “slingshot” ligaments). Since both dorsal ligaments cover the middle carpal column, the lunate is stabilized by the dorsal radiotriquetral ligament, and the capitate is stabilized from the dorsal side by the intercarpal ligament and held in colinear alignment. Two ligaments can be delineated from the dorsal joint capsule, which they fortify.

DICL

DRTL

Dorsal Radiotriquetral Ligament (DRTL) The extrinsic dorsal radiotriquetral ligament extends from the dorsal rim of the radius diagonally to the dorsal side of the triquetrum (Fig.10.5). In its course, it crosses the proximal scaphoid pole and the posterior horn of the lunate, near which the dorsal segments of the intrinsic SLL and LTL are closely associated with the DRTL. As a rule, this ligament originates on Lister’s tubercle of the radius. Accessory fascicles can, however, also originate from the styloid process of the radius or, further toward the ulnar aspect, from the dorsal rim of the radius.

Fig. 10.5 Diagram of the course of the dorsal extrinsic V-shaped ligaments. The dorsal radiotriquetral ligament (DRTL) extends proximally from the radius across the lunate to the triquetrum. The dorsal intercarpal ligament (DICL) extends distally from the triquetrum across the capitate to the scaphoid. In their course, the ligaments resemble a flat V.

Dorsal Intercarpal Ligament (DICL) This ligament, which is considered an intrinsic ligament because it passes between the carpal bones, takes a more horizontal course on the back of the hand. It originates at the dorsal side of the triquetrum and terminates with a fascicle on the back of the scaphoid (triquetroscaphoidal section of the ligament), with another fascicle on the back of the trapezium (triquetrotrapezial section) and at the radial collateral ligament (Fig.10.5). On its way, the ligamentary segments cross the neck of the capitate and the STT joints. Because they branch off at different levels, both DICL fascicles take different courses on the back of the hand.

Extensor Retinaculum The extensor retinaculum, which holds the extensor tendons in place like a hypomochlion, borders superficially to the dorsal ligaments. This is actually a double-layered thickening of the antebrachial fascia, which extends from the distal section of the forearm to the bases of the metacarpal bones. Between the superficial and deep layers of the retinaculum there are six compartments for the extensor tendons separated by septa. Lister’s tubercle

serves as a topographic landmark (bony prominence) that separates the second and third extensor-tendon compartments.

Carpal Collateral Ligaments These do not represent individual, delineated collateral ligaments but are thin-fibered fascicles reinforcing the carpal joint capsule on both sides of the wrist.

Radial Collateral Ligament (RCL) This thin radial collateral ligament extends from the tip of the styloid process of the radius to the outer side of the scaphoid at the level of its waist, to the tubercle of the trapezium, and to the flexor retinaculum. The RCL has no important stabilizing function. It is, however, important when the scaphoid is fractured in its middle third, where it is conductive to fragment dislocation.

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Ulnar Collateral Ligament (UCL) The ulnar collateral ligament is only a circumscribed reinforcement of the dorsal retinaculum. It originates at

the styloid process of the ulna and extends to the lateral aspect of the triquetrum and the hamate.

Pathoanatomical Principles The stability and the complex patterns of movement of the carpus are possible only when the carpal ligaments are intact. In diagnostic imaging of posttraumatic complaints, the scapholunate, lunotriquetral, and the radioscaphocapitate ligaments, as well as the triangular fibrocartilage complex (TFCC), are of special importance. The carpal ligaments can be damaged by trauma (often hyperextension injury), degenerative processes (already beginning after age 30), inflammatory diseases such as chondrocalcinosis (calcium pyrophosphate dihydrate deposition disease) and rheumatoid arthritis, and surgery (e.g., radical resection of the styloid process of the radius). Initially complaints and conventional radiographic diagnosis are usually uncharacteristic. Static instability of the carpus develops later and generally ends in osteoarthritis. Depending on the damaged ligament, but independent of the cause, the following typical patterns of instability can be differentiated: U Rupture of the SLL together with lesions of the extrinsic ligaments, which are still not entirely understood, leads to rotation of the lunate toward the dorsal aspect, a dorsiflexed intercalated segment instability of the carpus. U Conversely, a lesion of the LTL causes a palmar rotation of the lunate, or palmar intercalated segment instabil-

U

U

U

U

U

ity. In fully developed palmar malrotation, the extrinsic ligaments are also damaged. Instability of the TCSL and the DRTL on the ulnar aspect, whether due to constitutional looseness or a traumatic rupture, is an important predisposing factor for midcarpal instability. Distal radius fractures are often accompanied by rupture of the proximal palmar V-shaped ligaments and usually manifested as a DISI instability, which leads to posttraumatic complaints even after correct repositioning of the fragments. An isolated rupture of the RSCL (palmar support ligament) increases the natural flexion tendency of the scaphoid and, thereby, the palmar rotational malalignment of the scaphoid. A tear in the ligamentary system of the “extra-articular slingshot” (RSLL, RLTL, and DRTL) predisposes to ulnar translocation of the carpus, but also to a DISI configuration. The common origin of the dorsal V-shaped ligaments on the triquetrum explains the frequent avulsion fractures on the back of the triquetrum, where osteoligamentary avulsions of the DRTL and DICL occur (see Fig. 21.1).

Diagnostic Imaging Magnetic Resonance Imaging The methodological advantage of magnetic resonance (MR) imaging when compared to radiographic arthrography is direct visualization of the anatomy of the ligaments. The advantage when compared to arthroscopy is noninvasiveness. Since the size of carpal ligaments is in the millimeter range and often ligaments can be only poorly differentiated from their surroundings, high-resolution MRI techniques are used to visualize ligaments. An FoV of about 80 mm (100 mm at maximum) and slice thicknesses of 2 mm for two-dimensional (2D) sequences and 1 mm (and thinner) for three-dimensional (3D) sequences are necessary. The hand can be positioned in the center of the magnet with the patient lying prone to improve field homogeneity for fat-suppressed sequences, or “off

center” with the patient lying supine to enhance comfort. MRI visualization of the carpal ligaments can be achieved with sequences of different diagnostic information (Table 10.3). The imaging of ligaments depends considerably on the sequence used and the parameters applied: U Two-dimensional sequences for imaging of ligaments must have a slice thickness of 2 mm and an image matrix of at least 320 × 320. Because of the predominantly coronal alignment of the carpal ligaments and the triangular fibrocartilage complex (TFCC), slice acquisition should be performed in the coronal plane. To visualize the intrinsic ligaments and the TFCC, 12 coronal, continuously acquired 2 mm slices are sufficient. The SLL and its segments, as well as the TFCC, can always be visualized with this technique. For evaluation of the SLL and LTL, in addition to the coronal plane, axial, and,

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U

U

best of all, T2*-weighted slices are also helpful in analyzing the continuity of the dorsal and palmar segments. The much smaller LTL can be seen in about 80− 90 % of cases (Fig.10.7). Partial-volume effects must be taken into consideration when analyzing this delicate ligament. Failure to visualize the ligament should not always be considered evidence of rupture. All extrinsic ligaments have a paracoronal (oblique) course, and therefore only ligamentary segments are generally seen in 2D images. In spin-echo (SE) sequences, the carpal ligaments appear hypointense. Improved spatial resolution of ligaments is achieved by using 3D volume techniques with a partition thickness of 1 mm or, preferably, less than 1 mm, e. g. 0.5 mm. T2*-weighted 3D GRE sequences have proved especially suited for the visualization of ligaments. This type of sequence (FLASH technique) shows the TFCC in detail and with sufficient contrast to the articular cartilage and bones. The ligaments appear hypointense, but often display inclusions of intermediate signal intensity (see Chapter 9). Since the carpal ligaments extend predominantly in coronal or paracoronal plane, the coronal acquisition plane is best suited to capture these ligaments over longer distances in the “source images.” The high-resolution technique aims at a voxel size of 0.3 mm × 0.3 mm × 0.5 mm. Following acquisition, the 3D dataset must be submitted to multiplanar reconstruction (MPR). The paracoronal and parasagittal MPR slices are displayed parallel to the course of the ligament of interest. A work station that allows interactive, double-angled reconstruction slices and variable slice thicknesses (MPVR = multiplanar volume reconstruction, “thin MPR”) is advantageous because some carpal ligaments (radiolunotriquetral and dorsal intercarpal ligaments) have an arched course. Partialvolume effects are no longer important in the 3D technique; all intra-articular structures are available for image analysis. Diagnostic accuracy regarding the intrinsic ligaments and the triangular fibrocartilage can be considerably improved by MR arthrography. In the first step of this technique, a 1:200 diluted gadolinium solution is injected into the carpal joint compartments under fluoroscopic control, and then a high-resolution 2D dataset or 3D volume dataset is acquired. In comparison to diagnostic procedures without contrast enhancement, MR arthrography as a combined examination has three advantages: – Intra-articular injection of fluid separates and distends intra-articular ligaments and cartilaginous structures so that their dimensions can be well delineated. – The gadolinium solution provides an improved range of contrast in the joint space. In T1-weighted

sequences, the ligaments appear hypointense in contrast to the hyperintense surrounding liquid. An ideal tool for submillimeter 3D imaging is the novel VIBE sequence providing an excellent T1 contrast. – By enlarging the space and providing optimal surrounding contrast, the individual segments of the SLL and LTL can be well differentiated from one another, facilitating the location and size of ligamentary lesions. For diagnosis of abnormalities of the intrinsic ligaments, arthrography is performed in the midcarpal and radiocarpal joints. For diagnosis of TFCC abnormalities, arthrography is performed in the radiocarpal and the distal radioulnar joints.

Table 10.3 MRI of the carpal ligaments U

U

U

U

U

Contrast-enhanced Spin-Echo Sequences (SE) – Plain and contrast-enhanced after intravenous administration of contrast medium – T1-weighted SE sequence with high-resolution matrix (512 × 256) and a 2 mm slice thickness, or submillimeter 3D VIBE sequence – T1-weighted SE sequence with fat-saturation is useful for contrasting ligament/cartilage Gradient-Echo Sequences (2D GRE) – Plain T2*-weighted GRE sequence (e.g., FLASH 2D) – Flip angle ¥ between 10° and 30° 3D Gradient-Echo Sequences (3D GRE) – Usually plain T2*-weighted GRE sequence (e.g. FLASH 3D with in-plane matrix 256 × 256) – Hybrid sequences for cartilage: DESS 3D, MEDIC 3D – Optimal partition thickness is 1 mm, but submillimeter slices are also possible – High signal-to-noise ratio – Multiplanar reconstructions (MPR) along course of ligament is obligatory Direct MR arthrography – Contrast solution (gadolinium and x-ray dye in ratio 1:200) – Two-compartment arthrography (midcarpal and radiocarpal) for evaluation of the SLL and LTL – Two-compartment arthrography (radiocarpal and DRUJ) for evaluation of the triangular fibrocartilage complex (TFCC) – Three-compartment arthrography (midcarpal and DRUJ, radiocarpal) for evaluation of unclear complaints – In T1-weighted SE sequence with sat saturation or 3D sequences (3D VIBE, DESS, MEDIC) the ligaments appear in high contrast Indirect arthrography – Intravenous administration of gadolinium contrast agent – Then active carpal movement for 30–45 minutes – Sequences as in direct MR arthrography – Contrast and distending effect on intra-articular structures are smaller than with direct MR arthrography

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U

So-called indirect arthrography offers a similar, but less invasive approach (see Fig. 9.5 e, f ).

As described in detail in Chapter 23, the following characteristics can be seen in MRI when there is a lesion of a carpal ligament: U An abnormally long ligament (elongation without tear) U High-signal intensity within the ligament (sign of mucoid degeneration) U A focal dehiscence of the ligament (viewed at the rupture site) U Increased uptake of contrast medium (evidence of fibrovascular regeneration tissue) U A focal thickening of the ligament (due to ligamentary retraction) U No visualization of the ligament (sign of chronic wear and tear) After high-resolution MRI, therapy can be planned in accordance with the morphology, the location, and the extent of the ligament lesion. Normal anatomy of the carpal ligaments as seen on MR images is described below.

Scapholunate Ligament (SLL) In coronal MR slices, the three segments of the SLL can be seen to differ in shape, internal signal intensity, and osteochondral insertion. The visualized morphological patterns listed in Table 10.4 were originally described for T2*-weighted GRE sequences, but also apply to fatsaturated proton- (PD-)weighted or T2-weighted FSE sequences. Each of the three segments of the SLL displays a characteristic shape in coronal cross-sections (Fig.10.6 a–c): U In the palmar SLL segment, the ligament is generally shaped like a trapezoid. The palmar section is especially long because the scapholunate joint space is widest here and the fascicle has a slightly oblique course. U The middle segment of the SLL has a triangular or flattriangular shape in the coronal slice. U The dorsal section of the SLL appears as a uniform chord, i.e., as a line between the proximal pole of the scaphoid and the posterior horn of the lunate. Particularly, axial slices in which the continuity of the dorsal and palmar ligamentary segments can be checked are recommended (Fig.10.6 d). The intact segments bridge the scapholunate space as a hypointense strip across the cartilaginous surfaces. The collagen fibers of the ligament appear hypointense with inclusions of intermediate signal intensity caused by connective tissue and fibrovascular inclusions

(Table 10.5). These inclusions with higher signal intensity than the primarily hypointense SLL can differ in shape (round, linear) and location (central, peripheral extending to the surface of the ligament): U The palmar SLL has transverse stripes with obvious signal intensity. Anatomically, the stripes correlate with fibrovascular connective tissue. U In the middle (membranous) section of the ligament there can be a vertical inclusion of intermediate signal intensity, which can be mistaken for a tear when it reaches the surface of the ligament. U The signal intensity of the ligament decreases dorsally. The dorsal segment of the SLL generally appears homogeneously hypointense because it consists primarily of collagen fibers with only a small amount of fibrovascular tissue. For reporting assessment it is important to remember that the physiologic components in the ligament always have a lower signal intensity than a surrounding joint effusion (Table 10.5). A signal equivalent to fluid within the ligament, however, indicates a rupture. An area adjacent to the ligament with high-signal intensity can incorrectly be attributed to the SLL. This area is situated on the palmar side at the level of the transition between the scaphoid fossa and the lunate fossa of the radius and corresponds to fibrovascular tissue surrounding the RSLL. Because it is highly vascularized, it also has a slight physiologic enhancement. In the three scapholunate sections there are different kinds of osteochondral ligament insertions: U The palmar ligament fascicles are most commonly anchored directly to the bone on the scaphoid and lunate and extend as Sharpey’s fibers through the articular cartilage (Fig.10.6 c). Near their insertion, the hyperintense articular cartilage is interrupted focally by the hypointense ligament structures.

Table 10.4 MR morphology of the scapholunate ligament in the coronal plane when applying T2*-weighted 3D GRE sequences (modified according to Smith and Totterman) Segment of Ligament

Palmar

Form

Trapezoid

Triangular

Chord-shaped

Signal

Obviously inhomogeneous

Moderately inhomogeneous

Slightly inhomogeneous

Insertion

Bony

Chondral

Bony (chondral)

Cartilage

Homogeneously hyperintense

Double-line sign

(Double-line sign)

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Central

Dorsal

Diagnostic Imaging

b

_

a

Fig. 10.6 a–d MRI of the scapholunate ligament (arrows). a–c In coronal MR arthrography (T1-weighted SE sequence with fat saturation) precise delineation of a dorsal, b middle, and c palmar segments of the SLL. Note the different shapes and types of attachments of the SLL segments. d In plain T2*-weighted GRE sequence, the dorsal and palmar segments of the SSL appear as thin horizontal lines. The extrinsic radiolunotriquetral ligament extends across the palmar aspect (open arrow).

d c

U

U

The middle membranous section of the ligament inserts relatively uniformly on the articular cartilage of the scaphoid and lunate so that the hypointense bony and ligamentary structures are separated by a hyperintense band of cartilage (Fig.10.6 b). The dorsal ligament insertion can vary to a certain degree. A great majority of insertions are purely bony, i.e., there is a direct transition of the hypointense SLL into the similarly hypointense bony cortical layer without interposed cartilage (Fig.10.6 a). Less often there are combined osteochondral and purely chondral insertions, sometimes with different patterns of insertion on the scaphoid and lunate.

On the lunate side, Sharpey’s fibers are clearly thicker and stronger than on the scaphoid side. This asymmetric ligament configuration explains why ruptures occur primarily on the scaphoid side of the SLL after trauma and the larger remains of the ligament are found on the lunate (see Chapter 23). Special attention should be paid to the so-called “double-line sign” on articular cartilage, which can only be found with chondral types of insertion of the SLL, i.e., mostly in the middle third of the ligament. Immediately adjacent to the chondral fixation of the ligament is a thin, hypointense line on the scaphoid or lunate extending from the subchondral bone plate in a vertical or slightly

oblique transchondral course to the proximal surface of the articular cartilage. The anatomic correlate is assumed to be a changed course of the chondral collagen fibers. The hypointense line of the “double-line sign” must not be confused with the transchondral course of the SLL when it has a bony type of insertion.

Lunotriquetral Ligament (LTL) The lunotriquetral ligament is U-shaped, like the SLL, but is smaller in its extension from proximal to distal. Visualization of the LTL with MRI therefore requires high spatial resolution but does not succeed even in good imaging conditions in 10–15 % of cases. MRI characteristics are listed in Table 10.6. The functionally important ligament segments extend in dorsal and palmar courses, and are best seen in the coronal plane. Both segments appear as bands or triangular structures such that a horizontal linear pattern of fibers is seen in T2*-weighted 3D GRE sequences. This striped pattern is created by loose connective tissue surrounding the tight collagen ligamentary fibers. In both segments the LTL inserts usually directly into the cortical bone, i.e., the hypointense ligamentary fibers merge directly into the similarly hypointense compact bone (Fig.10.7 a). In contrast, the middle segment of the LTL, which is membranous and thinner, inserts into the artic-

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Table 10.5 Characterization of internal signals of the scapholunate ligament on MR images (according to Smith) Type

Form

1

No signal

2

Round

3

Relationship to Surface

Segment of Ligament

Pathoanatomy

Dorsal or all segments

Normal

Central

Middle and palmar

Degeneration

Longitudinal-linear

To the distal surface

Middle and palmar

Degeneration

4

Longitudinal-linear

To the proximal surface

Middle and palmar

Degeneration

5

Longitudinal-linear

To the proximal and distal surfaces

Middle

Perforation

ular cartilage (Fig.10.7 b). This hypointense middle segment is interrupted on both sides by lines of intermediate signal intensity representing articular cartilage covering the lunate and triquetral joints. These hyperintense cartilaginous inclusions should not be interpreted as lesions of the LTL. In T2*-weighted sequences, the LTL can only be visualized with a sensitivity and specificity between 50 % and 70 % in comparison to arthroscopy. If the clinical objective is specifically focused on the LTL, MR arthrography should be performed, as it provides diagnostic accuracy in evaluating the LTL of about 90 % in comparison to arthroscopy.

Radioscapholunate Ligament (RSLL), Radioscaphoid Ligament (RSL), and Radiolunate Ligament (RLL) These three palmar ligaments, which follow an extrinsic and interosseous course between the distal radius and the proximal carpus, can only be inconsistently visualized in MRI. They are best displayed in reconstructed sagittal or parasagittal slices and when a joint effusion is present. The radioscapholunate ligament (Testut’s ligament, RSLL) extends on the palmar side with two longitudinal, indistinctly delineated fascicles between the rim of the radius and the proximal scaphoid pole and lunate or the scapholunate ligament. At its insertion, this small ligament often cannot be distinguished from the scapholunate ligament (Fig.10.8 a). In contrast to the rest of the extrinsic ligaments, it does not have a streaky appearance but a homogenous intermediate signal intensity. The cause of this unique signal intensity is assumed to be the primarily neurovascular composition of the RSLL. The relatively good vascularization of the ligament, which fulfills no stabilizing function, explains the physiological enhancement after intravenous administration of contrast medium. The radioscaphoid ligament (RSL) and radiolunate ligament (RLL) are thickened parts of the palmar joint capsule in radial or ulnar position relative to the RSLL, which often cannot be delineated. The radioscaphoid fascicle inserts on the palmar side of the proximal scaphoid pole. The radiolunate fascicle inserts in a groove

on the palmar horn of the lunate (Fig.10.8 b) or merges before this point with the ulnolunate ligament. Since no stabilizing function has been determined for these small ligaments, the relevance of MRI in this carpal subregion for diagnosis of trauma or instability remains unclear.

Extrinsic Ligaments In contrast to the lack of visualization with arthrography and only partial visualization with arthroscopy, the extrinsic ligaments can be seen in their entire length with MRI. The palmar V-shaped ligaments (RLTL, RSCL, TCSL) and the dorsal ligaments (DRTL, DICL) extend obliquely to the orthogonal planes. They can therefore best be visualized in 3D datasets with secondary reconstruction in the MPR technique. The extrinsic ligaments appear striped in MRI. This characteristic pattern is caused by interpolation of hyperintense, loose connective tissue between the tight, hypointense collagenous fibers of the ligament. The palmar ligaments can be visualized in at least three consecutive slices if 1 mm-thick partition slices are chosen; the somewhat thinner dorsal ligaments can generally be seen in two consecutive slices. Especially good imaging conditions exist around the extrinsic ligaments if edema or synovitis surrounds the ligaments after an injury. Then the hypointense ligaments appear in strong contrast to the hyperintense background edema in a fat-saturated PD-weighted FSE sequence or to hyperintense background synovitis in an enhanced T1-weighted SE sequence. Table 10.7 summa-

Table 10.6 MR morphology of the lunotriquetral ligament in the coronal plane when applying T2*-weighted GRE sequences (modified according to Smith and Totterman) Segment of Ligament

Palmar

Central

Dorsal

Form

Triangular or chord-shaped

Triangular

Triangular or chordshaped

Signal

Inhomogeneous

Homogeneous

Inhomogeneous

Insertion

Bony

Chondral

Bony

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Diagnostic Imaging

Fig. 10.7 a, b MR arthrography of the lunotriquetral ligament. a Linear shape and cortical insertion in a dorsal T1weighted SE image. b Triangular shape and chondral insertion in a middle DESS image with water excitation.

a

b

This thin fascicle on the radial side of the joint capsule usually cannot be seen in normal MRI. If a large joint effusion, however, is present, the ligament insertion on the lateral aspect of the scaphoid can be identified.

separated by a synovial fold. Its important stabilizing function for the scaphoid has already been mentioned. On the palmar side of the scaphoid segments of this ligament can be identified as a hypointense structure in sagittal slices. The RSCL can be seen in its full length as a strong supporting ligament with a streaky pattern in 4−5, slightly paracoronally tilted 3D slices. In focal synovitis, e.g., after a scaphoid fracture, a strong gadolinium enhancement always delineates parts of the RSCL.

Radioscaphocapitate Ligament (RSCL)

Radiolunotriquetral Ligament (RLTL)

Of all the V-shaped ligaments, the RSCL occupies the furthest radial position on the carpus. Distal of the radiolunotriquetral ligament it extends in a diagonal course from the styloid process of the radius across the waist of the scaphoid to the head of the capitate (Fig.10.9). On the palmar side of the scaphoid the RSCL is not fixed, but is

Ulnarly and proximally, the thick RLT ligament joins the RSCL, from which it is separated by an interligament gap. With a deep fascicle the RLTL connects the styloid process of the radius and the palmar horn of the lunate, where it can cause a focal signal decrease. A superficial fascicle extends to the palmar side of the triquetrum, where it

rizes MRI data concerning morphometry of the extrinsic ligaments.

Radial Collateral Ligament (RCL)

_

a

b

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Fig. 10.8 a, b MR arthrography of the “small” interosseous ligaments. a Radioscapholunate ligament (arrow) in a postarthrographic T1-weighted SE sequence with fat saturation. Coronal slice far to the palmar aspect. b Radiolunate ligament (arrow), the so-called “short RL ligament”, in a postarthrographic sagittal T1-weighted SE image. The position of the radioscaphocapitate ligament (open arrow) can be seen palmar to the capitate.

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Table 10.7 Morphometric data for MRI of the extrinsic carpal ligaments (according to Smith) Extrinsic Ligaments

Width (mm)

Thickness (mm)

Radioscaphocapitate ligament

22.2 ± 1.4

2.2 ± 0.4

Radiolunotriquetral ligament

Ø

2.3 ± 0.5

Ulnolunate ligament

11.6 ± 1.5

2.5 ± 0.6

Ulnotriquetral ligament

11.4 ± 0.7

3.7 ± 0.5

Arcuate ligament (TCSL)

21.4 ± 2.2

2.8 ± 0.7

Dorsal radiotriquetral ligament

22.4 ± 2.4

2.2 ± 0.4

Dorsal intercarpal ligament

Ø

Ø

Ø = No measurement possible because of the multiplanar-oblique ligament course.

inserts in a proximal groove. The RLTL appears over a long length with a striped linear pattern in paracoronal slices of a 3D dataset (Fig.10.10). In the presence of synovitis, the RLTL can regularly be visualized in coronal slices.

Ulnolunate ligament (ULL) and ulnotriquetral ligament (UTL) The ulnocarpal ligaments (ulnolunate and ulnotriquetral ligaments) are the components of the palmar-stabilizing

ligament system on the ulnar side. They represent peripheral, well-vascularized fortifying ligaments of the TFCC. They often have a common palmar origin from the middle third of the triangular fibrocartilage. The ULL, which extends obliquely to the palmar horn of the lunate, can best be seen in parasagittal slices. The UTL extends longitudinally to the front of the triquetrum, where it attaches in a groove proximal to the pisotriquetral joint (see Fig.11.3 c). It can be visualized in both parasagittal and paracoronal slices. Sometimes both ligaments supply fibers to the lunotriquetral ligament. The other structural

Fig. 10.9 a, b MRI of the radioscapholunate ligament (RSLL). a In a sagittal T1-weighted SE image, the RSLL (arrow) extends on the palmar side of the scaphoid. b MR arthrogram with visualization of the RSLL (arrow) and the RLTL (open arrow).

_

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a

b

Fig. 10.10 a, b MRI of the radiolunotriquetral ligament (RLTL). a The PD FSE sequence with fat saturation clearly shows the course of the RLTL (arrows) between the scaphoid, lunate, and triquetrum. b MR arthrogram (T1 SE sequence with fat saturation) shows the radiolunate section of the RLTL with high contrast. a

b

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Diagnostic Imaging

elements of the triangular fibrocartilage complex are explained in Chapter 11.

datasets. Very rarely a bony or chondral “os centrale” is seen in the ligament near the scaphoid insertion.

Triquetrocapitoscaphoid (“Arcuate”) Ligament (TCSL)

Dorsal Radiotriquetral Ligament (DRTL)

The arcuate ligament, which constitutes the distal section of the palmar V-shaped ligaments, extends transversely deep in the carpal tunnel from the palmar side of the triquetrum to the scaphoid tubercle. In MRI it is most easily identified in axial images, where it appears as a hypointense structure between the carpal bones and the deep flexor tendons (Fig.10.11 a). This robust ligament has variably arched fascicles. Between the sites of attachment, there is either a solitary triquetroscaphoid ligament or a fascicle that inserts on the palmar waist of the capitate (triquetrocapitate ligament) before it continues to the distal pole of the scaphoid (capitoscaphoid ligament). The arcuate ligament has a streaky appearance similar to that of the other extrinsic ligaments (Fig.10.11 b). A ligamentary fiber extending to the palmar horn of the lunate can occasionally be seen in 3D

The radiotriquetral ligament originates at Lister’s tubercle on the dorsal radius, crosses the posterior horn of the lunatum transversely, where it sometimes also attaches, and inserts on a bony protuberance on the back of the triquetrum (Fig.10.12). In 2D coronal images, the slightly curved ligament is visualized over a short distance only, and is best depicted with a fat-saturated PD-weighted FSE sequence or with a gadolinium-enhanced and fatsaturated T1-weighted SE sequence. In this plane, the DRTL usually cannot be distinguished from the dorsal segments of the SLL and the LTL. In sagittal slices, it appears as a “spot” dorsal of the proximal scaphoid pole and the posterior horn of the lunate. The DRTL has variations in both its origins and course. These can be classified into three different ligament types in 3D MRI by means of paracoronal reconstructions:

Fig. 10.11 a, b Multiplanar reconstruction of the arcuate ligament (TCSL) from a 3D T2* GRE sequence. a In the axial plane, the ligament is seen deep in the carpal tunnel. b Visualization of the triquetrocapitate segment of the TCSL (arrow) in a paracoronal reconstruction plane.

a

b

_ Fig. 10.12 Courses of the dorsal radiotriquetral ligament (arrow) and the dorsal intercarpal ligament (open arrow). PD-weighted FSE sequence with fat saturation.

Fig. 10.13 Transverse orientation of the extensor retinaculum. High ligament-to-surrounding contrast is caused by synovitis in a contrast-enhanced T1-weighted SE sequence with fat saturation.

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U

U

U

Type 1: solitary DRTL that originates on the ulnar aspect of Lister’s tubercle. Type 2: DRTL plus fibers on the radial aspect that originate at the styloid process of the radius. Type 3: DRTL plus fibers on the ulnar aspect that originate at the dorsal rim of the radius. Sometimes ligament fibers can be identified that extend to the extensor carpi ulnaris (ECU) tendon sheath and the dorsal radioulnar ligament.

Dorsal Intercarpal Ligament (DICL) The intrinsic intercarpal ligament originates at a dorsal protrusion on the triquetrum and extends over the neck of the capitate, ending with variable attachment on striplike extensions of the scaphoid and the trapezium, as well as the radial collateral ligament (Fig.10.12). The DICL, like the DRTL, can be visualized over some distance in coronal slices. In sagittal slices a long, oval-shaped, hypointense structure can be seen for a short distance dorsal of the proximal carpal row. Three different ligament courses can be differentiated in paracoronal MR images of a T2*-weighted 3D dataset: U Type 1: a broad, solitary DICL without fibers branching off. U Type 2: a forked DICL: two separate fascicles extend from a common origin on the triquetrum to the scaphoid and to the trapezium. U Type 3: two separate ligament fascicles, the triquetroscaphoid and the triquetrotrapezium.

Extensor Retinaculum The stabilizing extensor retinaculum borders superficially on the dorsal ligaments of the wrist. It is a continuation of the antebrachial fascia, which appears hypointense in all MRI sequences (Fig.10.13). From the distal segment of the forearm to the bases of the metacarpals, there are six separate compartments for the extensor tendons separated by septa between the layers of the retinaculum. A ligamentary fiber can often be seen extending from the extensor retinaculum to the triquetrum.

Arthrography After having injected a contrast medium intra-articularily, the intra-articular ligaments are indirectly visualized by means of a chordlike contrast-free area. To obtain complete visualization of the carpal ligaments, two examinations are performed: the three-compartment

method with arthrography of the midcarpal joint and the distal radioulnar joint in the first sitting, and arthrography of the radiocarpal joint in a second sitting two hours after injection of contrast material (Chapter 3). With the exception of the radioscapholunate and the radiolunate ligaments, the interosseous ligaments, especially the scapholunate and the lunotriquetral ligaments, as well as the elements of the triangular fibrocartilage complex, can generally be visualized arthrographically. The ligaments of the distal palmar V and the dorsal V, however, completely escape arthrographic visualization. For patients beyond the age of 35 years, the examiner must be aware of physiological “pinhole” defects and perforations. In this age group and beyond, only bidirectional defects are generally considered pathologic. In inconclusive cases, intercompartimental communication of the contrast medium must be compared with that of the non-affected hand.

Arthroscopy After the joint is distended with carbon dioxide or fluid, a 30° optical system is introduced through an appropriate access on the extensor side into the radiocarpal, midcarpal, or distal radioulnar joint. This invasive procedure offers the advantage of allowing the examiner to perform endoscopic therapy during the same sitting (Chapter 4). Only a portion of the carpal ligaments can be seen during arthroscopy. The radioscapholunate, scapholunate, and lunotriquetral ligaments and the structures of the triangular fibrocartilage complex (ulnolunate and ulnotriquetral ligaments and the triangular fibrocartilage), as well as the scaphotrapeziotrapezoid ligament, can be assessed well. Age-dependent changes, especially perforated ligaments, must be kept in mind. Arthroscopic landmarks are the well-vascularized radioscapholunate ligament (RSLL, Testut’s ligament), which separates the compartment of the scaphoid fossa from that of the lunate fossa. Even though the RSLL appears strong in arthroscopy, it serves no supportive function because it contains only a few collagen fibers. Of the extrinsic ligaments, only the proximal ones, i.e., the radial sections of the radioscaphocapitate and the radiolunotriquetral ligaments, can be inspected. On the ulnar aspect, the distally-located triquetrocapitoscaphoid (arcuate) ligament cannot be seen. The dorsal ligaments (dorsal radiotriquetral and dorsal intercarpal ligaments) cannot be seen because of the angle of access. The diagnostic information of different imaging procedures for the carpal ligaments is summarized in Table 10.2.

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Diagnostic Imaging

Further Reading Adler BD, Logan PM, Janzen DL et al. Extrinsic radiocarpal ligaments: Magnetic resonance imaging of normal wrists and scapholunate dissociation. Can Assoc Radiol J. 1996;47:417–422. Berger RA, Landsmeer JMF. The palmar radiocarpal ligaments: A study of adult and fetal human wrist joints. J Hand Surg. 1990;15A: 847–854. Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg. 1996;21A:170–178. Brown RR, Fliszar E, Cotten A, Trudell D, Resnick D. Extrinsic and intrinsic ligaments of the wrist: Normal and pathologic anatomy at MR arthrography with three-compartment enhancement. Radiographics. 1998;18:667–674. Daunt N. Magnetic resonance imaging of the wrist: Anatomy and pathology of interosseous ligaments and the triangular fibrocartilage complex. Curr Prob Diagn Radiol. 2002;31:158–176. Gilula LA, Palmer AK. Is it possible to diagnose a tear at arthrography or MR imaging? Radiology. 1993;187:582–587. Gilula LA, Hardy DC, Totty WG, Weeks PM. Fluoroscopic identification of torn intercarpal ligaments after injection of contrast material. Am J Roentgenol. 1987;149:761–764. Gundry CR, Kursunoglu-Brahme S, Schwaighofer B, Kang HS, Sartoris DJ, Resnick D. Is MR better than arthrography for evaluating the ligaments of the wrist: In vitro study. Am J Roentgenol. 1990;154:337–341. Hajek PC, Baker LL, Sartorius DJ. MR arthrography: Anatomic-pathologic investigation. Radiology. 1987;163:143–147. Hajek PC, Sartoris DJ, Gylys-Morin V et al. The effect of intra-articular gadolinium-DTPA on synovial membrane and cartilage. Invest Radiol. 1990;25:179–183. Jacobson JA, Oh E, Propeck T, Jebson PJ, Jamadar DA, Hayes CW. Sonography of the scapholunate ligament in four cadaveric wrists: correlation with MR arthrography and anatomy. Am J Roentgenol. 2002;179:523–527. Kang HS, Kindynis P, Kursunoglu-Brahme S et al. Triangular fibrocartilage and intercarpal ligaments of the wrist: MR imaging, cadaveric study with gross pathologic and histologic correlation. Radiology. 1991;181:401–404. Kovanlikaya I, Camli D. Diagnostic value of MR arthrography in detection of intrinsic carpal ligament lesions: Use of cine-MR arthrography as a new approach. Eur Radiol. 1997;7:1441–1445. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: Value of the three-compartment injection method. Radiology. 1991;179: 231–239. Linkous MD, Pierce SD, Gilula LA. Scapholunate ligamentous communicating defects in symptomatic and asymptomatic wrists: Characteristics. Radiology. 2000;216:846–50. Manaster BJ. The clinical efficacy of triple-injection wrist arthrography. Radiology. 1991;178:267–270. Mayfield JK, Johnson P, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. 1976;186:417–428. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am. 1984;15:209–216. Metz VM, Mann FA, Gilula LA. Three-compartment wrist arthrography: Correlation of pain site with location of uni- and bidirectional communications. Am J Roentgenol. 1993;160: 819–822. Mizuseki T, Ikuta Y. The dorsal carpal ligaments: Their anatomy and function. J Hand Surg. 1989;14B:91–98. Poirier P, Charpey A. Traite d’anatomie humaine. Vol. 1. Paris: Masson et Cie; 1911:226. Reuther G, Erlemann R, Grünert J, Peters PE. The examination technique and normal morphology of the ligaments in MRT of the wrist. Radiologe. 1990;30:373–379. Rominger MB, Bernreuther WK, Kenney PJ, Lee DH. MR Imaging of anatomy and tears of wrist ligaments. Radiographics. 1993;13: 1233–1246.

Scheck RJ, Kubitzek C, Hierner R et al. The scapho-lunate interosseous ligament in MR arthrography of the wrist: Correlation with nonenhanced MRI and wrist arthroscopy. Skeletal Radiol. 1997;26: 263–271. Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: Correlation with standard MRI and wrist arthroscopy. J Magn Reson Imag. 1999;9:468–474. Schmidt HM, Lanz U. Surgical Anatomy of the Hand. Stuttgart: Thieme; 2004. Schmitt R, Fellner F, Fellner C, Cavallaro A, Dobritz M, Bautz W. Visualization of wrist ligament injuries using contrast enhanced MRI. Radiology. 1998;209P:609. Schmitt R, Christopoulos G, Meier R et al. Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients. [in German] Fortschr Röntgenstr. 2003;175:911–919. Sennwald G. The Wrist. Anatomical and Pathophysiological Approach to Diagnosis and Treatment. Heidelberg: Springer; 1987. Sennwald GR, Zdravkovic V, Oberlin C. The anatomy of the palmar scaphotriquetral ligament. J Bone Joint Surg. 1994;76B:147–149. Smith DK. Dorsal carpal ligaments of the wrist: Normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. Am J Roentgenol. 1993;161:119–125. Smith DK. Volar carpal ligaments of the wrist: Normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging. Am J Roentgenol. 1993;161:353–357. Smith DK, Snearly WN. Lunotriquetral interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists. Radiology. 1994;191:199–202. Smith D. Scapholunate interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists. Radiology. 1994;192:217–221. Smith DK. MR imaging of normal and injured wrist ligaments. MRI Clin North Am. 1995;3:229–248. Stäbler A, Kohz P, Baumeister RGH, Reiser M. Diagnostik von karpalen Bandverletzungen und Kapselerkrankungen durch die kontrastmittelverstärkte Magnetresonanztomographie (MRT). Radiologe. 1995:35(90). Stäbler A, Spieker A, Bonel H et al. Magnetic resonance imaging of the wrist—comparison of high resolution pulse sequences and different fat signal suppression techniques in cadavers. Fortschr Röntgenstr. 2000;172:168–174. Taleisnik J. The ligaments of the wrist. J Hand Surg. 1976;1:110–118. Taleisnik J. The Wrist. New York: Churchill Livingstone; 1985:13–38. Theumann NH, Pfirrmann CW, Antonio GE et al. Extrinsic carpal ligaments: normal MR arthrographic appearance in cadavers. Radiology. 2003;226:171–179. Theumann NH, Pfirrmann CW, Antonio GE et al. MR imaging of the major carpal stabilizing ligaments: Normal anatomy and clinical examples. Radiographics. 1995;14:575–587. Totterman SMS, Miller R, Wasserman B, Blebea JS, Rubens DJ. Intrinsic and extrinsic carpal ligaments: Evaluation by three-dimensional Fourier transform MR imaging. Am J Roentgenol. 1993;160: 117–123. Totterman SMS, Miller RJ. Scapholunate ligament: Normal MR appearance on three-dimensional gradient-recalled-echo images. Radiology. 1996;200:237–241. Wright TW, Del Charco MD, Wheeler D. Incidence of ligament lesions and associated degenerative changes in the elderly wrist. J Hand Surg. 1994;19A:313–318. Zanetti M, Bram J, Hodler J. Triangular fibrocartilage and intercarpal ligaments of the wrist: Does MR arthrography improve standard MRI? J Magn Reson Imaging. 1997; 7:590–594.

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Triangular Fibrocartilage Complex R. Schmitt

The triangular fibrocartilage complex (TFCC) is a differentiated fibroligamentary structure located between the ulnar head, the lunate and the triquetrum on the ulnar side of the wrist. Approximately one-fifth of the axial load of the wrist is transferred by the TFCC, and it is the most important stabilizer of the distal radioulnar joint, as well as of the ulnar side of the carpus. The triangular fibrocartilage (TFC) in the center is differentiated from the peripheral TFCC elements,

consisting of the dorsal and palmar radioulnar ligaments, the ulnolunate and ulnotriquetral ligaments, the tendon sheath of the extensor carpi ulnaris muscle, and the ulnar collateral ligament. Arthroscopy and MRI are most appropriate for imaging these structures. The avascular TFCC center is best visualized with direct MR arthrography, and the vascularized TFCC periphery, with contrast-enhanced MRI.

Fundamental Anatomy The triangular fibrocartilage complex (TFCC) (also known as the ulnocarpal complex) acts as a buffer and stabilizer between the ulnar head and the ulnar segment of the proximal carpal row (lunate, triquetrum). The triangular fibrocartilage complex is immediately adjacent to the distal radioulnar joint and constitutes a functional unit with this joint. The dome-shaped TFCC is a complex anatomical and biomechanical structure consisting of fibrocartilaginous and ligamentary elements (Fig.11.1): U The most important component, the triangular fibrocartilage (TFC), is a centrally located cushion between the ulnar head and the ulnar carpus. With the exception of its periphery, the TFC is a bradytropic tissue, and thus poorly vascularized (avascular segment). U The peripheral components of the TFCC consist of synovial folds, which are variable, and ligaments, which ensure fixation and stability. The ligaments are arranged on the palmar and ulnar sides of the TFCC. In comparison to the TFC, the peripheral components of the TFCC are relatively well vascularized (vascular segment).

Table 11.1 Components of the triangular fibrocartilage complex U U U U U U U

Triangular fibrocartilage (TFC) Ulnolunate ligament Ulnotriquetral ligament Meniscus homologue Ulnar collateral ligament Palmar and dorsal radioulnar ligaments Sheath of the extensor carpi ulnaris tendon

Table 11.1 summarizes the individual components of the triangular fibrocartilage complex. The triangular fibrocartilage complex has three important functions: U The TFCC is an important stabilizer for the distal radioulnar joint (Fig.11.1 e). U Moreover, the ligaments of the TFCC stabilize the ulnar side of the carpus during movement in the radiocarpal joint, as well as in the distal radioulnar joint (Fig.11.1 a, d). U Approximately 20 % of the axial load of the wrist is transferred via the shock-absorbing TFC (about 80 % is transferred via the radiocarpal compartment). The topographic anatomy of the individual components of the TFCC is briefly described below.

Triangular Fibrocartilage (TFC) The TFC consists of fibrous cartilage and originates with a broad base from the articular cartilage of the radius at the level of the ulnar notch (Fig.11.1 b). After following a horizontal course, it inserts on the ulna with two peripheral fascicles, which have a streaky appearance. One fascicle extends ulnobasal to the fovea in the ulnar head, and the other to the tip of the styloid process of the ulna (insertion type I). Well-vascularized connective tissue lies between the two ulnar fascicles. In rare cases, the TFC terminates in a single fascicle that broadly inserts on the styloid process (insertion type II). In an axial crosssection, the TFC appears as an equilateral triangle. In the periphery (limbus), which consists of lamellar collagen fibers, the triangular fibrocartilage is thicker (up to

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Fundamental Anatomy

a

b

ulnoapical attachment

lunotriquetral ligament

ulnar collateral ligament

ulnobasal attachment

of the triangular fibrocartilage

radial attachment

meniscus homologue ulnotriquetral ligament ulnolunate ligament ulnar recess articular cartilage

palmar radioulnar ligament

sacciform recess

joint capsule

lunate fossa c

scaphoidal fossa

tendon of the extensor carpi ulnaris meniscus homologue ulnar collateral ligament ulnar recess ulnotriquetral ligament ulnolunate ligament

d

e

ulnar collateral ligament meniscus homologue

triangular fibrocartilage

lunotriquetral ligament

sigmoid notch of the radius dorsal radioulnar ligament joint capsule

dorsal radioulnar ligament joint capsule tendon sheath of the extensor carpi ulnaris

Fig. 11.1 a–e Diagrams of the anatomy of the triangular fibrocartilage complex (TFCC). a View from the palmar aspect of the TFCC. Note the sac-like bulge of the ulnar recess on the left edge of the diagram. b Coronal slice through the middle of the TFCC. The origin of the triangular fibrocartilage (TFC) on the articular cartilage of the radius and the ulnobasal and ulnoapical fascicles are visible. The meniscus homologue and the ulnocarpal ligaments are outside the plane.

c Distal view of the radiocarpal joint surface and the TFCC. The joint surface of the radius continues smoothly into the surface of the TFC. The two radioulnar ligaments surround the edges of the TFC. d Dorsal view of the TFCC. Note the tendon and the tendon sheath of the extensor carpi ulnaris (ECU) muscle. The dorsal radiotriquetral ligament, which does not belong to the TFCC, is not shown. e Proximal and dorsal views of the TFCC after removal of the ulna. The proximal side of the TFC is shown.

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5 mm) than in the center. This difference in thickness causes a biconcave disk-shaped appearance in sagittal and coronal cross-sections. The relative length of the ulna must be considered when assessing the average thickness of the TFC. A short ulna (minus variant) is accompanied by a relatively thick TFC, and a long ulna (plus variant) by a relatively thin TFC. The TFC has a particular form of blood supply in that only the periphery is well vascularized by blood vessels that radiate into it, whereas the obviously larger central and radial segments are avascular. The radioulnar ligaments and, on the palmar aspect, the ulnolunate and ulnotriquetral ligaments are attached to the edges of the TFC disc.

Palmar Radioulnar Ligament (PRUL) and Dorsal Radioulnar Ligament (DRUL) In contrast to the TFC, these two “controlling” ligaments of the distal radioulnar joint originate directly from the compact bone of the distal radius (Fig.11.1 a, d). These streaky-looking ligaments extend inside the joint capsule in very close relationship to the TFC, from which they are separated only by a thin layer of cells, and cannot be differentiated by imaging. Due to their fixation at the radius, the TFC, and the ulnar head, both radioulnar ligaments contribute essentially to the stabilization of the distal radioulnar joint and the TFCC. Because the two ligaments are woven into a spiral, they continually keep the distal radioulnar joint under tension during rotation of the forearm.

Meniscus Homologue (MH) This structure, which consists of connective tissue, is a relic of evolution, i.e., of the articulation between the ulnar head and the triquetrum that is still evident in primates. This relatively poorly delineated structure consists of a fold of synovial mucous membrane and loose connective tissue. The meniscus homologue originates at the dorsoulnar border of the triangular fibrocartilage and extends obliquely to the palmar and ulnar aspects

(Fig.11.1 a, c, d). In its course it swings around the styloid process of the ulna and forms the roof of the ulnar (prestyloid) recess. The meniscus homologue terminates on the palmar side of the triquetrum, the hamate, and the bases of metacarpals IV/V, as well as on the ulnar collateral ligament. It also stabilizes the pisotriquetral joint.

Ulnolunate Ligament (ULL) This ligament is located in the joint capsule. It is one of two palmar TFCC stabilizers. It originates at the palmar radioulnar ligament and extends in a diagonal course to the palmar horn of the lunate (Fig.11.1 a). Fibers often radiate into the lunotriquetral ligament. Like the ulnotriquetral ligament, the ULL contributes to the stability of the radiocarpal and the distal radioulnar joints.

Ulnotriquetral Ligament (UTL) This second stabilizing ligament on the palmar aspect of the TFCC is located on the ulnar side. The UTL originates from the palmar radioulnar ligament either alone or together with the ULL (Fig.11.1 a). It extends steeply to a depression on the palmar side of the triquetrum.

Tendon Sheath of the Extensor Carpi Ulnaris (ECU) Muscle The ECU tendon sheath, a very thin structure, is integrated into the dorsal segment of the TFCC, where it lies in a groove on the dorsal side of the ulnar head (Fig.11.1 c, d). It is attached to the extensor retinaculum, which arches over the tendon.

Ulnar Collateral Ligament (UCL) The UCL is a chordlike thickening of the ulnar side of the joint capsule (Fig.11.1 a, d). Its very existence and delineation from the capsule are controversial in the literature.

Pathoanatomic Principles Traumatic lesions (partial and complete ruptures) or degenerative changes (mucoid inclusions and perforations) can be manifested in the triangular fibrocartilage complex (TFCC). It is assumed that a rupture often occurs where there is already degeneration of the TFCC. From a therapeutic and prognostic point of view, alterations in the avascular segment of the triangular fibrocartilage (TFC) must be differentiated from those in the wellvascularized periphery:

U

U

Individuals at least 30 years of age generally already have degenerative lesions of the TFC. These begin with the formation of mucoid inclusions, which cause wide perforations in the radial and central segments of the TFC when they reach the surface. After a short while the TFC perforation results in chondropathy of the articular cartilage lining the ulnar head, the lunate and triquetrum. The final stage is an ulnolunotriquetral impaction syndrome.

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Diagnostic Imaging

U

U

U

When a lesion of the TFCC is already present, it is often accompanied by damage to the lunotriquetral ligament with or without development of carpal instability. Ruptures of the TFC generally occur in the immediate vicinity of the radial origin and also frequently on the ulnar attachment. Injuries to the radioulnar ligaments always lead to instability in the distal radioulnar joint. If the palmar

radioulnar ligament is involved, the radius dislocates to the palmar aspect. Conversely, an injury to the dorsal ligament leads to a dorsal shift of the radius in the distal radioulnar joint. Injuries to the ulnolunate and the ulnotriquetral ligaments can promote radiocarpal instability of the carpus.

U

Diagnostic Imaging The components of the TFCC can best be visualized with MRI. Arthroscopy, however, remains the diagnostic standard of reference. Since arthroscopy is an invasive procedure, therapeutic measures can be carried out in the same sitting.

Magnetic Resonance Imaging Examination Techniques Because extension of the TFCC is in the millimeter range, it can only be visualized with sufficient diagnostic quality if the following examining conditions are fulfilled. U Field strength and gradient field strength: To achieve a sufficient signal-to-noise ratio, as well as high spatial resolution within an acceptable scan time, high-capacity equipment with field strengths of 1.0 or 1.5 T and gradient field strengths of at least 20 mT/m must be used. Low-field scanners of 0.2 or 0.5 T visualize the bony morphology of the carpus, but the carpal ligaments and the TFCC always escape certain assessment. U Surface coils: The use of dedicated surface coils is obligatory on the carpus. Flexible wraparound coils and 2-, 4- or 8-channel coils in phased-array technology are available for this purpose. The latter provide the best images. U Application of contrast medium: The accuracy of diagnostic assessment of the triangular fibrocartilage complex is significantly increased by the intravenous and/or intra-articular administration of contrast medium. The surface contour and structural dehiscences accompanying perforations and ruptures of the intrinsic ligaments and the triangular fibrocartilage are visualized with distension and a high contrast-to-noiseratio in MR arthrography. Fibrovascular regenerative tissue, which appears in the damaged TFCC periphery a few days after injury, can be identified and localized with high sensitivity by means of intensive enhancement after intravenous administration of contrast medium.

Appropriate sequences: As explained in Chapters 9 and 10, the sequences listed in Table 11.2 are best suited for visualization of the TFCC on MRI.

U

The fat-saturated PD-weighted FSE sequence (Fig. 11.2 a, c) and the contrast-enhanced T1-weighted SE sequence (Fig.11.2 b) are best suited for two-dimensional imaging. T2*-weighted GRE sequences (FLASH or FSPGR with an ¥ of 15−30°) and a hybrid DESS-type sequence (with T1 and T2* fractions) are the best suited of the threedimensional sequences (see Table 10.11). The 3D datasets with nearly isotropic voxels permit radial multiplanar reconstruction (MPR) of the TFC. The center of reconstruction is placed in the styloid process of the ulna, and the reconstruction segment extends between the dorsal and palmar borders of the sigmoid notch of the radius. A scan field of 8 cm or 10 cm edge length and slice thicknesses of 2 mm for 2D sequences and 1 mm or less for 3D sequences are desirable. Three-dimensional imaging permits MPR in the direction of interest, e.g., parallel to the ulnobasal and ulnoapical fibers of the TFC or the ulnolunate and ulnotriquetral ligaments. The following text briefly describes the normal anatomy of the triangular fibrocartilage complex as seen on MR images.

Table 11.2 MRI sequences for visualization of the triangular fibrocartilage complex U U U

U

U

T2*-weighted GRE sequence (2D or 3D imaging) PD-weighted FSE sequence (fat saturated) Plain and contrast-enhanced T1-weighted SE sequence (fat saturated) or 3D VIBE sequence Postarthrographic T1-weighted SE sequence (fat saturated) Postarthrographic T2*- or T2*-/T1-weighted 3D GRE sequences

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lunotriquetral ligament ulnoapical fascicle of the TFC

dorsal radioulnar ligament

connective tissue ulnobasal fascicle of the TFC

ulnar head

articular cartilages of the sigmoid notch of the radius and the ulnar head

tendon of the extensor carpi ulnaris

a Coronal slice through the dorsal segment of the TFCC (fatsaturated PD-weighted FSE sequence). The dorsal radioulnar ligament originates from the bony dorsal rim of the radius. The ECU tendon is also visible.

b Coronal slice through the middle of the TFCC (fat-saturated T1-weighted SE slice after intravenous administration of contrast medium). The TFC originates from the articular cartilage of the sigmoid notch of the radius. Note the interposition of hyperintense connective tissue between the two fascicles of the TFCC on the ulnar side.

dorsal radioulnar ligament

meniscus homologue

tendon of the extensor carpi ulnaris

ulnar collateral ligament

sigmoid notch of the radius

ulnobasal fascicle of the TFC

c Coronal slice through the palmar section of the TFCC (fat-saturated PD-weighted FSE sequence). The meniscus homologue is shown in direct continuation of the TFC. There is a physiological amount of joint effusion.

palmar radioulnar ligament

d Axial slice through the distal radioulnar joint (T2*-weighted GRE sequence). Both radioulnar ligaments and the tendon of the extensor carpi ulnaris, which lies in a groove on the dorsal side, can be seen.

Fig. 11.2 a–d Normal anatomy of the triangular fibrocartilage complex (TFCC) on MR images.

Triangular Fibrocartilage (TFC) In all sequence types, the TFC appears as a horizontal hypointense chord (Figs. 11.2 b, 11.3b, 11.4). In the preferred coronally acquired slices, but also in sagittal slices, the TFC looks like a biconcave disk because of its circumferential, thickened rim (limbus). The thickness of the TFC can differ in relationship to the length of the ulna. It has an average thickness of 1.1 mm ± 0.6 mm in the middle, 1.8 mm ± 0.6 mm at the dorsal edge, and 1.4 mm ± 0.6 mm at the palmar edge with a normal variance of the

ulna. The proximal surface of the TFC borders directly on the articular cartilage covering the ulnar head; its distal surface borders on the articular cartilage of the lunate and triquetrum. Joint effusion, if present, appears between the layers of cartilage. The aging process, which begins as early as age 30, is responsible for inclusions of intermediate signal intensity in the TFC, which can best be seen in T2*-weighted GRE sequences. These hyperintense inclusions, which can regularly be found either in the center without surface contact or in the periphery with surface contact,

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Diagnostic Imaging

ulnotriquetral ligament

meniscus homologue

palmar radioulnar ligament a

TFC

Fig. 11.3 a–c Palmar structures of the triangular fibrocartilage complex. a After administration of contrast agent, the curved course of the meniscus homologue becomes visible in the T1weighted SE sequence with fat saturation. Mild synovitis improves the delineation. b, c The ulnocarpal ligaments are located furthest on the palmar side. The ulnotriquetral ligament is shown here in a sagittal T2*weighted GRE sequence, as well as in a coronal enhanced T1-weighted SE sequence with fat saturation.

b

ulnotriquetral ligament c

represent mucoid degeneration of the fibrous cartilage. With suboptimal imaging techniques, these can also be caused by blurring artifacts. The most important criterion differentiating them from a tear in the TFC or a perforation (full-thickness tear) is their level of signal intensity. Degenerative inclusions have intermediate signal intensity. Ruptures or perforations have hyperintense, water-equivalent signals. An area of high signal intensity appears on the ulnar side of the TFC and is caused by connective and fatty tissue between the two ligament fascicles attached to the TFC (Fig.11.2 b). The ulna is attached to the TFC by two ligament fascicles, which, like the TFC, have low signal intensity. In rare cases, there is only one strong fascicle. In 2D sequences, the extensions on the ulnar margin of the TFC do not appear to reach their sites of attachment on the fovea of the ulnar head or on the tip of the ulnar styloid process because of the partial volume effect on these thin fibers. The surface of the TFC and its structural integrity can best be assessed in images from MR arthrography (Fig.11.4). Plain MRI provides the worst basis for an assessment because of the physiologic signal inclusions

resulting from the aging process. The peripheral vascularization of the TFC can be evaluated only with enhanced MRI. The center of the TFC is avascular, but the periphery (limbus), with the exception of the radial side, is well vascularized by nutrient vessels entering it from outside. Therefore, lesions to the center of the TFC can best be identified with MR arthrography, whereas peripheral lesions are best seen in contrastenhanced sequences. Possible pitfalls in diagnosis of the TFCC withplain T2-weighted sequences are summarized in Table 11.3.

Palmar Radioulnar Ligament (PRUL) and Dorsal Radioulnar Ligament (DRUL) These two ligaments originate at the palmar and dorsal edges of the sigmoid notch of the radius, which are not covered with cartilage. In contrast to the TFC, they insert directly on the compact bone (Fig.11.2 a). In a converging course they extend to the ulnar side almost to the ulnar styloid process, where they unite with the ulnobasal fascicle of the TFC. Loose connective tissue enclosed between the collagen fibers in the radioulnar ligaments

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MH and with its roof as a port of the MH, can constitute a pitfall (Fig.11.4). meniscus homologue

ulnar recess

TFC

Fig. 11.4 MR arthrography of the ulnar (prestyloid) recess. The postarthrographic coronal slice shows the fluid-filled ulnar space (fat-saturated T1-weighted SE slice in palmar localization). The recess is ulnar of the meniscus homologue, which constitutes the dorsal aspect and the roof of the opening.

Ulnolunate Ligament (ULL) and Ulnotriquetral Ligament (UTL) These two ligaments, which stabilize the TFCC on the palmar aspect, have an oblique course. They extend from the palmar radioulnar ligament, on which they can have a common origin, to the palmar sides of the lunate and triquetrum. Sometimes ligamentary fascicles to the lunotriquetral ligament can be seen in 3D sequences. These two ligaments can best be depicted in parasagittal or paracoronal 3D thin slices (Fig.11.3 b, c), but only occasionally in standard planes of 2D sequences. Further details can be found in Chapter 10.

Tendon Sheath of the Extensor Carpi Ulnaris (ECU) Muscle gives them a streaky appearance in T2-/T2*-weighted sequences. Because of their converging course toward the ulnar side (Fig.11.1 d), these ligaments extend beyond strictly coronal slices, and, as with the TFC, only segments can be imaged. If subluxation in the distal radioulnar joint is present, the radioulnar ligaments should be analyzed for discontinuity and liquid inclusions.

Meniscus Homologue (MH) The meniscus homologue, a fold of connective tissue, has intermediate signal intensity in all MR sequences. Visualization is difficult because the meniscus homologue extends diagonally from the dorsal edge of the TFC to the palmar side of the triquetrum and hamate and to the ulnar collateral ligament. Orthogonal standard planes show only segments of the MH. It is best seen in coronal slices (Figs. 11.2c, 11.3 a). The ostium of the ulnar (prestyloid) recess, which borders on the palmar side of the

The normally thin ECU tendon sheath is best visualized in axial T2*-weighted slices (Fig.11.2 d). The tendon sheath appears as a hyperintense ring peripheral to the hypointense center of the tendon. The ring-shaped groove on the dorsal side of the ulnar head, which serves as a track, and the extensor retinaculum (as a fixation) can also be seen in the axial plane. In comparison to the turbo spin-echo sequences, T2*-weighted GRE sequences differentiate the ECU tendon from the tendon sheath with far greater constrast. Because of the partial-volume effect, visualization can be poor in coronal slices.

Ulnar Collateral Ligament (UCL) The UCL cannot always be differentiated as an independent structure from the joint capsule in coronal MRI sequences (Fig.11.2 c). MRI has methodological advantages over arthroscopy in that it visualizes the internal tissue structure of

Table 11.3 Diagnostic pitfalls caused by signal alterations in the triangular fibrocartilage complex MR Imaging Findings

Anatomical Correlate

Pitfalls and Differential Diagnosis

Hyperintense, vertical signal line at the radial origin

Articular cartilage of the radius

Complete rupture according to Palmer Type IA or ID with fluid retention

Hyperintense signal area between the ulnar ligamentary fascicles and the ulnar styloid process

Physiologic connective and fatty tissue on the ulnar aspect (Lig. subcruetum)

Complete rupture according to Palmer Type IB with fluid retention

Area of increased signal intensity on the ulnar side

“Magic angle” effect due to oblique fibers

Complete rupture according to Palmer Type IB with fluid retention

Hyperintense signal area on the palmar side of the ulnar styloid process

Fluid retention in the adjacent ulnar recess

TFC degeneration according to Palmer Type IIC–IIE with fluid retention

Hypointense, thin signal line in the center of the TFC

Surfaces of the articular cartilage on the ulnar head and the lunate

TFC degeneration according to Palmer Type IIA (thinning) versus IIC (perforation)

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Diagnostic Imaging

the TFC and the ligaments, thereby demonstrating stages of degeneration before a surface lesion has occurred.

Ulnar (Prestyloid) Recess A recess in the joint capsule can regularly be seen on the ulnar side of the wrist. This space, which can always be identified in arthrography, serves as a reservoir for extra synovial fluid in the radiocarpal compartment (Fig.11.4). The location of the ulnar recess is palmar and proximal of the ulnar styloid process. The structures bordering the ulnar recess can be visualized well in MRI. These structures are the ulnar styloid process on the dorsal aspect, the meniscus homologue on the distal aspect, the fascicles of the TFC on the radial and ulnodistal sides, and the joint capsule and the ECU tendon sheath on the ulnar side.

Arthroscopy For diagnosis of lesions on the ulnar side of the wrist, arthroscopy of the radiocarpal joint is performed with accesses via the 3–4 or 4–5 portals. The distal surface of the TFC and the peripheral ligaments of the TFCC can be viewed directly during arthroscopy. In normal conditions, the surface of the radial fossa lunata extends continuously to a smooth meniscal surface because the TFC serves as a shock absorber and completely equalizes the levels of the radius and the ulna (see Fig. 4.4 c). This assessment criterion cannot, of course, be applied to the proximal side of the TFC because arthroscopy of the distal radioulnar joint is only infrequently performable. The tension and elasticity of the TFCC can, however, be tested with an examining hook. Normally there is a so-called “trampoline effect,” which confirms the integrity of the TFC and the ligaments in the periphery. Both criteria–direct inspection and palpation with an examining hook–make arthroscopy the current reference method for diagnosis of lesions of the triangular fibrocartilage complex (see Fig. 4.6). An arthroscopic operation (débridement of a central TFC lesion, arthroscopic suture of a peripheral TFCC lesion) can be performed in the same diagnostic sitting.

Arthrography As a two-compartment examination with injection of contrast medium into the radiocarpal joint (see Fig. 3.2 c) and the distal radioulnar joint (Fig. 3.2 b), arthrography

offers a sensitive method of identifying degeneration and ruptures of the TFC. The technical procedure is described in Chapter 3. If no contrast medium enters the distal radioulnar joint during radiocarpal arthrography, which visualizes the distal surface of the TFC, arthrography of the distal radioulnar joint with injection of contrast medium immediately follows for examination of the proximal surface of the TFC. Complementary spot films under fluoroscopic control are advised for documentation of a discrete TFC lesion. Arthrographic diagnosis of the triangular fibrocartilage complex has two severe methodological limitations: U Only the triangular fibrocartilage can be assessed. The remaining structural elements—the meniscus homologue, the radioulnar, ulnolunate, and ulnotriquetral ligaments, and the ECU tendon sheath—cannot be visualized arthrographically. U As a projection procedure, arthrography does not adequately permit differentiation of traumatic or degenerative lesions of the TFC and determination of the extent of the lesion. For these reasons, in the era of high-resolution CT and MRI, arthroscopy of the wrist should always be combined as MR arthrography (or CT arthrography) and never be performed merely as an individual arthrographic examination (see Fig. 3.5).

Radiographic Diagnosis The TFCC cannot be visualized in conventional radiographs. Views in neutral position serve only to estimate the thickness of the TFC on the basis of the relative length of the ulna. With a short ulna (negative ulnar variance), a lunate osteonecrosis resulting from increased axial load in the radiolunate compartment must be excluded; and with a long ulna (positive ulnar variance), an ulnolunate neoarticulation with manifestation of an impaction syndrome must be excluded.

Computed Tomography Plain computed tomography (CT) is not helpful in assessing the TFCC. The TFC cannot be sufficiently visualized because of only slight absorption differences and streaky artifacts caused by bones. However, CT arthrography with contrast filling of the radiocarpal and distal radioulnar joints has been proved to be very useful in detecting TFC lesions.

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Further Reading Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangulare fibrocartilage complex: Its clinical significance. J Hand Surg. 1991;16A:1101–1105. Benjamin M, Evans EJ, Pemberton DJ. Histological studies on the triangular fibrocartilage complex of the wrist. J Anat. 1990;172: 59–67. Chidgey LK. Histologic anatomy of the triangular fibrocartilage. Hand Clin. 1991;7:249–262. Daunt N. Magnetic resonance imaging of the wrist: Anatomy and pathology of interosseous ligaments and the triangular fibrocartilage complex. Curr Prob Diagn Radiol. 2002;31:158–176. Gabl M, Lener M, Pechlaner S, Judmaier W. The role of dynamic magnetic resonance imaging in the detection of lesions of the ulnacarpal complex. J Hand Surg. 1996;21B:311–314. Gilula LA, Palmer AK. Is it possible to diagnose a tear at arthrography or MR imaging? Radiology. 1993;187:582–587. Gilula LA, Hardy DC, Totty WG. Wrist arthrography: An updated review. J Med Imag. 1988;2:252–266. Haims AH, Schweitzer ME, Morrison WB et al. Limitations of MR imaging in the diagnosis of peripheral tears of the triangular fibrocartilage of the wrist. Am J Roentgenol. 2002;178:419–422. Haims AH, Schweitzer ME, Morrison WB et al. The effect of intraarticular gadolinium-DTPA on synovial membrane and cartilage. Invest Radiol. 1990;25:179–183. Hajek PC, Sartoris DJ, Gylys-Morin V et al. Arthrographic surface anatomy of the carpal triangular fibrocartilage. J Hand Surg. 1988;13A:823–829. Herold T, Lenhart M, Held P et al. Indirect MR arthrography of the wrist in the diagnosis of TFCC-Lesions. [in German] Fortschr Röntgenstr. 2001;173:1006–1011. Herold T, Lenhart M, Held P et al. Does high-resolution MR imaging have better accuracy than standard MR imaging for evaluation of the triangular fibrocartilage complex? J Hand Surg. 2000;25: 487–491. Kang HS, Kindynis P, Kursunoglu-Brahme S et al. Triangular fibrocartilage and intercarpal ligaments of the wrist: MR imaging, cadaveric study with gross pathologic and histologic correlation. Radiology. 1991;181:401–404. Kauer JMG. The articular disc of the hand. Acta Anat. 1975;93: 590–605. Keogh CF, Wong AD, Wells NJ, Barbarie JE, Cooperberg PL. High-resolution sonography of the triangular fibrocartilage: Initial experience and correlation with MRI and arthroscopic findings. Am J Roentgenol. 2004;182:333–336. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: Value of the three-compartment injection method. Radiology. 1991;179: 231–239. Manaster BJ. The clinical efficacy of triple-injection wrist arthrography. Radiology. 1991;178:267–270. Mikic ZD. Age related changes in the triangular fibrocartilage of the wrist. J Anat. 1978;126:367–384. Mikic Z. Detailed anatomy of the articular disc of the distal radioulnar joint. Clin Orthop. 1989;245:123–132. Metz VM, Schratter M, Dock WI et al. Age-associated changes of the triangular fibrocartilage of the wrist: Evaluation of the diagnostic performance of MR imaging. Radiology. 1992;184:217–222. Nakamura T, Yabe Y, Horiuchi Y. Fat suppression magnetic resonance imaging of the triangular fibrocartilage complex. Comparison with spin-echo gradient echo pulse sequences and histology. J Hand Surg. 1999:248:22–26. Oneson SR, Scales LM, Timins ME, Erickson SJ, Chamoy L. MR imaging interpretation of the Palmer classification of triangular fibrocartilage complex lesions. Radiographics. 1996;16:97–106.

Pfirrmann CW, Theumann NH, Chung CB, Botte MJ, Trudell DJ, Resnick D. What happens to the triangular fibrocartilage complex during pronation and supination of the forearm? Analysis of its morphology and diagnostic assessment with MR arthrography. Skeletal Radiol. 2001;30:677–685. Potter HG, Asnis-Ernberg L, Weiland AJ, Hotchkiss RN, Peterson MG, McCormack RR Jr. The utility of high-resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist. J Bone Joint Surg. 1997;79A:1675–1684. Quinn SF, Belsole RS, Greene TL, Rayhack M. Postarthrography computed tomography of the wrist: evaluation of the triangular fibrocartilage complex. Skeletal Radiol. 1989;17:565–569. Reinus WR, Hardy DC, Totty WG, Gilula LA. Arthrographic evaluation of the carpal triangular fibrocartilage complex. J Hand Surg. 1987; 12A:495–503. Reuther G, Erlemann R, Grünert J, Peters PE. The examination technique and normal morphology of the ligaments in MRT of the wrist. [in German] Radiologe. 1990;30:373–379. Scheck RJ, Romagnolo A, Hierner R, Pfluger T, Wilhelm K, Hahn K. The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy. J Magn Reson Imag. 1999;9: 468–474. Sennwald G. The Wrist. Anatomical and Pathophysiological Approach to Diagnosis and Treatment. Heidelberg: Springer; 1987. Schmidt HM, Lanz U. Surgical Anatomy of the Hand. Stuttgart: Thieme; 2004. Schmitt R, Fellner F, Fellner C, Cavallaro A, Dobritz M, Bautz W. Visualization of wrist ligament injuries using contrast enhanced MRI. Radiology. 1998;209P:609. Schmitt R, Christopoulos G, Meier R et al. Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients. [in German]. Fortschr Röntgenstr. 2003; 175:911–919. Skahen JR 3rd, Palmer AK, Levinsohn EM, Buckingham SC, Szeverenyi NM. Magnetic resonance imaging of the triangular fibrocartilage complex. J Hand Surg. 1990;15A:552–557. Stäbler A, Kohz P, Baumeister RGH, Reiser M. Diagnostik von karpalen Bandverletzungen und Kapselerkrankungen durch die kontrastmittelverstärkte Magnetresonanztomographie (MRT). [in German] Radiologe. 1995:35(90). Stäbler A, Spieker A, Bonel H et al. Magnetic resonance imaging of the wrist—comparison of high resolution pulse sequences and different fat signal suppression techniques in cadavers. [in German] Fortschr Röntgenstr. 2000;172:168–174. Sugimoto H, Shinozaki T, Ohsawa T. Triangular fibrocartilage in asymptomatic subjects: Investigation of abnormal MR signal intensity. Radiology. 1993;191:193–197. Totterman SMS, Miller RJ. Triangular fibrocartilage complex: Normal appearance on coronal three-dimensional gradient-recalled-echo MR images. Radiology. 1995;195:521–527. Vahlensieck M, Peterfy CG, Wischer T et al. Indirect MR arthrography: Optimization and clinical indications. Radiology. 1996:200: 249–254. Wright TW, Del Charco MD, Wheeler D. Incidence of ligament lesions and associated degenerative changes in the elderly wrist. J Hand Surg. 1994;19A:313–318. Yoshioka H, Ueno T, Tanaka T, Shindo M, Itai Y. High-resolution MR imaging of triangular fibrocartilage complex (TFCC): Comparison of microscopy coils and a conventional small surface coil. Skeletal Radiol. 2003;32:575–581. Zanetti M, Bram J, Hodler J. Triangular fibrocartilage and intercarpal ligaments of the wrist: Does MR arthrography improve standard MRI? J Magn Reson Imaging. 1997;7:590–594. Zanetti M, Linkous MD, Gilula LA, Hodler J. Characteristics of triangular fibrocartilage defects in symptomatic and contralateral asymptomatic wrists. Radiology. 2000;216:840–845.

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Carpal Morphometry and Function R. Schmitt, K. J. Prommersberger

Anatomically, the carpus represents a complex mosaic of skeletal elements with a multitude of joint surfaces. Functionally, not only sufficient stability but also a high range of motion must be ensured. Correct analysis of static radiographs of the carpus in the neutral position requires the systematic application of carpal

lines, carpal angles, and length indices. Movements of the wrist are complex and involve several joint compartments and spatial planes, whereby radial inclination is synchronically combined with flexion and ulnar inclination, with extension.

Morphometry and Function of the Distal Forearm The radius makes up three-fourths of the joint socket of the wrist, consisting of the fossa scaphoidea and the fossa lunata of the radius, and one-fourth is formed by the triangular fibrocartilage complex (TFCC). The sigmoid notch of the radius adjoins the ulnar side of the socket and cradles the ulnar head in the distal radioulnar joint (Fig.12.1).The radiocarpal joint surface of the radius is tilted toward the ulnar and palmar aspects. A tendency of the carpus to drift because of this slope is prevented by a group of ligaments that pull in the opposite direction— the so-called “extra-articular slingshot ligaments” (RSLL, RLTL, RSCL, and DRTL), which extends from proximalradial to distal-ulnar, and the so-called “palmar support ligaments” (RSCL, RLTL, ULL, UTL). These ligaments are discussed in detail in Chapter 10.

Joint Angle of the Distal Radius Segment The frontal angle of the radius (ulnar inclination of the radius) is measured in dorsopalmar radiographs with the wrist in neutral position (Fig.12.2 a). This refers to the angle between two connecting lines: U A tangent drawn between the tip of the radial styloid process and a point in the middle between the palmar and dorsal corners of the sigmoid notch of the radius, U A line drawn perpendicular to the longitudinal axis of the radius (DiBenedetto’s method) or the longitudinal axis of the ulna (Matsushita’s method). The mean value of the frontal angle of the radius is 23° (normal range: 15−35°).

radial styloid process Lister’s tubercle

sigmoid notch

scaphoid fossa lunate fossa Fig. 12.1 Joint surfaces of the distal radius. 3D surface model from a CT dataset after electronic exarticulation of the ulna and the carpus.

In case of malunion of distal radius fractures, determination of both the dorsal and palmar values of the frontal angle is useful as it enables already the sagittal malalignment of the radius in dorsopalmar radiographs. If there is a pathological dorsal tilt, the ulnodorsal corner of the radius is proximal to the ulnopalmar edge. The sagittal angle of the radius (radius tilt, palmar inclination) is determined in the lateral radiograph of the wrist in neutral position (Fig.12.2 b), where the distal radius should be visualized for a length of at least 6 cm. This is defined as the angle between the line drawn perpendicular to the longitudinal axis of the radius and a tangent between the corners of the dorsal and palmar rims of the radius in the lateral radiograph. The mean palmar inclination of the radius is 11° (normal range 0−20°).

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a

Fig. 12.2 a, b Determination of the angles of the radius. a Frontal angle of the radius (according to DiBenedetto). As explained in the text, point C is placed in the middle of the dorsal and palmar corners of the radius on the ulnar side. The frontal angle of the radius lies between the points DCE. The mean angle is 23° (range 15−35°). The distance between points D and E correlates with the height of the radial styloid process. b Sagittal angle of the radius (according to Mann). The angle is measured between a line drawn perpendicular to the longitudinal axis of the radius and the tangent on the corners of the palmar and dorsal rims of the radius. The mean angle is 11°.

b

D E

C

A

A

B B

Radioulnar Translation

Relative Lengths of the Radius and the Ulna The length ratio between the radius and the ulna, known as the ulnar variance, may only be determined in dorsopalmar radiographs of the wrist in neutral position because of the translational movement during pronosupination of the forearm. Of the different methods of determining the ratio, Gelberman’s is the most commonly used (Fig.12.3). A 2 mm difference in length between the radius and the ulna is considered normal. The height of the radial styloid process is determined in dorsopalmar radiographs. The value is defined as the distance between the tip of the radial styloid process and a line drawn perpendicular to the longitudinal axis of the radius which touches the sigmoid notch distally (Fig.12.2 a). It is useful to determine this value in chauffeurs’ fractures (Chapter 17). The normal value is between 11 and 13 mm (normal range 8−17 mm).

The relative length of the ulna changes during pronosupination of the forearm. The ulna assumes a distal position in relation to the radius during pronation and a proximal position during supination. Nonstandardized imaging procedures can therefore mimic a long ulna (positive ulnar variance) or a short ulna (negative ulnar variance).

A

B

Fig. 12.3 Determination of the ulnar variance according to Gelberman’s method.

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Morphometry and Function of the Carpus

Rotation of the Forearm (Pronosupination)

Fig. 12.4 Distal radioulnar joint in neutral position. Note the congruence of the joint surface of the sigmoid notch of the radius and the ulnar head. View from distal onto the joint surfaces of a 3D surface model (calculated from a CT dataset after electronic exarticulation of the carpus).

Rotation of the forearm and the hand is carried out in constant-phase congruence at the proximal and distal radioulnar joints. The mean range of rotational motion in pronation is 85° and in supination is 90°. The starting point is the neutral position, i.e., the upper arm adducted, the elbow flexed 90°, and the palm facing medially (Chapter 1). Rotation in the distal radioulnar joint takes place around the ulna as a fixed point around which the radius rotates together with the hand. The radius sweeps over the surface of a conic segment. The greatest possible congruence of the joint surfaces exists in neutral position (Fig.12.4). During pronation and supination the joint surfaces of the ulnar head and the sigmoid notch of the radius have less contact (see Fig.1.2).

Morphometry and Function of the Carpus Radiographic Carpal Arches The bones of both carpal rows are arranged so that they form three harmonious parallel arches in dorsopalmar radiographs (Fig.12.5): U The first carpal arch connects the proximal contours of the proximal carpal row. U The second carpal arch connects the distal contours of the proximal carpal row. U The third carpal arch connects the proximal contours of the distal carpal row. Every interruption or step in an arch must arise suspicion of an articular derangement contributing to carpal instability. Arches that are not parallel are suspicious for an unstable carpus. A triangle-like lunate, which is normally trapezoidal in shape in dorsopalmar radiographs, should be also considered pathologic.

mine the radiolunate, radioscaphoid, scapholunate, and capitolunate angles (Figs. 12.6, 12.7). Either the axial method (connecting lines between the middle of the proximal and distal joint surfaces) or the tangential method (a tangent along the palmar aspect of the scaphoid and the dorsal side of the capitate and a line perpendicular to the line connecting the anterior and posterior horns of the lunate) is used for this purpose. Normal values and ranges are listed in Table 12.1. When the carpus is intact, the longitudinal axes through the radius, the lunate, and the capitate, as well as through metacarpal III, can be lengthened in a straight line, i.e., these axes are arranged colinear (see Fig.12.9 a). Because of the physiological variations and inaccuracies in measurement (especially of the lunate), a colinear connecting line is found in only about 10 % of healthy hands. Results within the normal ranges are, therefore, considTable 12.1 Normal carpal angles Angle

Carpal Angles Measuring four angles in lateral radiographs (in neutral position!) facilitates the recognition of discrete carpal malalignment. Longitudinal axes are drawn through the radius, the lunate, the scaphoid, and the capitate to deter-

Mean Value

Normal Range

Radiolunate

0°

-15° to + 15°

Radioscaphoid

0°

30° to 60°

Scapholunate

47°

30° to 60°

Capitolunate

0°

-15° to +15°

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of the carpus is assessed by comparing the length of the carpus with that of the adjacent metacarpus. Two indices are available (Fig.12.8): U Youm’s index of carpal height: The ratio of the length of the carpus (measured by continuing the longitudinal axis along the axis of metacarpal III) and the length of metacarpal III. The normal value is 0.54 ± 0.03. U Nattrass’ modified index of carpal height: If the metacarpus is not entirely on the radiograph, the ratio the

ered normal. Images depicting abnormal results can be found in Chapter 23.

Carpal Height The proximal carpal row can be reduced in height in the presence of carpal instabilities, lunate osteonecrosis, and unstable scaphoid nonunion. The longitudinal extension

a

b

C

C S

III II

S

I L

L

R

Fig. 12.6 a, b Determination of the longitudinal axis for the scaphoid (S), lunate (L), capitate (C), and radius (R). a In the axial method, connecting lines are drawn through the middle of the proximal and distal joint surfaces. b In the tangential method, a tangent is drawn along the palmar side of the scaphoid and along the dorsal side of the capitate. A line is drawn perpendicular to the line connecting the anterior and posterior horns of the lunate (broken line).

Fig. 12.5 Radiographic carpal arches (according to Gilula). In normal alignment of the carpus, continuous and harmonious lines can be drawn along the proximal (I, II) and distal (III) carpal rows. The connecting lines are parallel.

a

b

R

c

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d

Fig. 12.7 a–d Determination of the carpal angles. The carpal angles between the depicted bones are determined by the axial method. a Radioscaphoid angle. The diagram depicts a normal 45° angle of a normal carpal alignment. b Radiolunate angle. Abnormal 22° angle in a slight DISI malalignment. c Capitolunate angle. Pathologic 37° angle in severe DISI malalignment. d Scapholunate angle. Normal 47° angle and normal carpal alignment.

Morphometry and Function of the Carpus

a

b a

U

a

d

e

and the length of metacarpal III. The normal value is 0.28 ± 0.03. Abnormal values are greater. McMurtry’s translation index: The ulnar side of the carpus is measured. The ratio is calculated between the distance from the center of rotation to a perpendicular line drawn through the middle of the ulnar head and the length of metacarpal III. The normal value is 0.30 ± 0.03. Pathologic values are smaller.

Carpal Movement Planes and Axes

c b

Fig. 12.8 a, b Height and translation indices of the carpus. a Indices of carpal height according to Youm and to Nattrass. a = the length of metacarpal III; b = the height of the entire carpus; c = the length of the capitate. Youm’s index of carpal height is the ratio b/a; Nattrass’ index of carpal height is the ratio b/c. b Carpal translation indices according to Chamay and to McMurtry. The black circle represents the carpal rotation center, which is located in the capitate head; the dotted lines run through the radial styloid process and the middle of the ulnar shaft. The distances d and e are perpendicular to the dotted lines. Chamay’s carpal translation index is the ratio d/a; McMurtry’s translation index is the ratio e/a.

length of the carpus (measured by continuing the longitudinal axis of the capitate) and the length of the capitate is calculated. The normal value is 1.57 ± 0.05.

The wrist can be regarded as a modified condyloid joint whose condyle is composed of seven carpal bones. The defined coordinated movements of the carpal bones are not based on a static condyle but on a mobile system of joints that can adjust their form to correspond to the prevailing spatial and force requirements according to the principle of variable geometry. The arrangement of joints in the moving carpus is coordinated by the alignment of the joint surfaces and also by the control of the carpal ligaments. Movement takes place not only between the two carpal rows (intercarpal), but also between the individual carpal bones (intracarpal). The range of motion is relatively large among the components of the proximal carpal row and small in the distal carpal row because of their stronger ligament fixation. In combination with the carpal joints, the radiocarpal joint has two degrees of freedom (flexion/extension and radial/ulnar inclination). The proximal and distal radioulnar joints lend a third degree of freedom (pronosupination). These movements can be carried out either in isolation or in combination in the three spatial planes (Table 12.2).

Ulnar Deviation of the Carpus Two indices can quantify ulnar deviation of the carpus caused by trauma, degeneration, or rheumatoid arthritis (Fig.12.8 b). The point of reference is always the rotational center of the carpus in the head of the capitate: U Chamay’s translation index: The radial side of the carpus is measured. The ratio is calculated between the distance from the center of rotation to a perpendicular line drawn through the styloid process of the radius

Flexion and Extension Flexion and extension movements take place in the radiocarpal joint, as well as in the midcarpal joint (Fig.12.9 a). Articular movements in flexion with an average of 80° and in extension with an average of 85° are each distributed about 50/50 in the two compartments of the wrist. Note that ranges of motion of the scaphoid and lunate are different in the sagittal plane. Because of the

Table 12.2 Planes and axes in carpal movement Movement

Plane of Movement

Axis of Movement

Flexion–extension

Sagittal

Transverse

(x axis)

Radial inclination–ulnar inclination

Coronal

Sagittal

(y axis)

Pronation–Supination

Axial

Longitudinal

(z axis)

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smaller curvature of its proximal joint surface, the scaphoid is capable of greater movements in flexion and extension than the lunate in the radiocarpal joint (Fig.12.9 b, c). However, the relative motion between the scaphoid and the lunate is limited to between 15° and 20° by the scapholunate ligament, which passes between the two bones.

Radial and Ulnar Inclination An average radial inclination of 24° and an average ulnar inclination of 40° is normally possible. The center of rotation is the center of the head of the capitate. During abduction, the two carpal rows move in opposite directions: U During radial inclination (Fig.12.10 a–c), the proximal carpal row rotates slightly to the ulnar side, and the distal row moves in the opposite direction to the radial side. U During ulnar inclination (Fig.12.10 d–f), the proximal carpal row slides to the radial side and the distal row to the ulnar side.

Two groups of palmar ligaments, which form a “V” in neutral position, change their shape during ulnar or radial inclination into two L-shaped structures. The ligament bundles move antagonistically and are either relaxed or stretched during rotation or translation movements. Movements during radial or ulnar inclination are not limited to the coronal plane but are combined with complex rotational processes of the proximal carpal row in the sagittal plane. Radial inclination of the carpus is accompanied by flexion movements of the proximal carpal row, whereby ulnar inclination is accompanied by extension movements. The individual movements that take place during radial and ulnar inclination are explained below and are summarized in Table 12.3. During radial inclination of the carpus: U The scaphoid rotates into flexion (Fig.12.10 b). The proximal pole of the scaphoid moves slightly in a dorsal direction. In the dorsopalmar radiograph, the flexed scaphoid with its distal pole causes the socalled “ring sign.” U The lunate also rotates to the palmar aspect (Fig.12.10 c). The palmar flexed intercalated segment instability configuration of the central carpal column

b

c

a Fig. 12.9 a–c 3D model of different carpal sections from a CT dataset. a Ulnar view of the central carpal column consisting of the lunate and capitate. The rest of the carpals has been removed. The radiolunate and capitolunate joint compartments are easily recognizable. b Documentation of the scapholunate alignment. In the view from ulnar, the scaphoid displays a palmar angulation of its longitudinal axis of about 45° in relation to the lunate. The rest of the carpals has been removed.

c Removal of the lunate and the ulnar head offers an unobstructed view of the radioscaphoid articulation. The joint surface of the proximal scaphoid pole, which is centered in the radial fossa scaphoidea, has an obviously smaller curvature than that of the lunate (Fig. 12.9 b).

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Morphometry and Function of the Carpus

Fig. 12.10 a–f Carpal kinematics during radial and ulnar inclination. During radial inclination, a the distal carpal row rotates to the radial side, and the proximal row to the ulnar side. Simultaneously the proximal row rotates toward the palmar side, as shown in sagittal CT images b at the level of the scaphoid and c at the level of the lunate. Rotations occur in the opposite directions during ulnar inclination. d shows movements of both carpal rows to the radial and to the ulnar side, respectively, as well as rotation of the proximal row in extension as seen in CT images e of the scaphoid and f of the lunate.

b

a

c

e

d

f

results from the coupling of the lunate with the scaphoid and the triquetrum via the scapholunate and lunotriquetral ligaments. Furthermore, the capitate, which is in relative extension, presses the lunate toward the palm. U The triquetrum slides into a proximal (so-called “low”) position. The triquetrum moves dorsally and rotates toward the palm on the spiral-shaped joint surface of the hamate. During ulnar inclination of the carpus: U The scaphoid rotates into extension (Fig.12.10 e). The proximal pole of the scaphoid moves slightly toward the palmar aspect. The extended scaphoid appears lengthened in the dorsopalmar radiograph.

U

U

The lunate also rotates toward the dorsal aspect (Fig.12.10 f). The dorsiflexed intercalated segment instability (DISI) configuration of the central carpal column, which is obvious in the lateral view, results from coupling of the lunate with the scaphoid and triquetrum via the scapholunate and lunotriquetral ligaments. Furthermore, the lunate is shifted dorsally by the capitate, which is in relative flexion. The triquetrum slides into a distal (so-called “high”) position. Because of the spiral-shaped hamatotriquetral joint surface (Fig.12.11), the triquetrum moves simultaneously toward the palm in relation to the hamate and also rotates dorsally.

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Concepts of Carpal Stability and Instability

Fig. 12.11 Hamatotriquetral joint in a three-dimensional view. In the 3D view of the pisotriquetrohamate region, which was reconstructed from a CT dataset, the spiral-shaped configuration of the joint surface between the triquetrum and hamate can be clearly seen. The anatomy of the joint surfaces clarifies the rotational components of the triquetrum when it slides from a distal (high) into a proximal (low) position and vice versa.

In dorsopalmar radiographs, the relative “high” and “low” positions of the triquetrum in relation to the hamate cause alternating overlapping of both bones on the ulnar side of the wrist (Fig.12.10 a, d).

In general, stability of two adjacent joint partners is defined as the ability to maintain their normal position to one another under normal loads. Various concepts have been developed to analyze and explain carpal instability, but no individual concept alone satisfactorily explains the normal or abnormal kinematics of the carpus. U Fisk’s concept of carpal rows differentiates a proximal from a distal row. By bridging both rows, the scaphoid stabilizes the midcarpal joint, whereby carpal movements are partially synchronized. U According to Taleisnik’s concept of carpal columns, flexion and extension are carried out via the central column (lunate, capitate, hamate, trapezium, and trapezoid), while the medial column (triquetrum) permits rotational movements especially in the hamatotriquetral joint. The scaphoid represents the lateral column. U Static and dynamic derangements of the carpus are currently best explained by Lichtman’s concept of the oval ring of the carpus. According to this concept, the carpus consists of a ring of bones in which both carpal rows move in opposite directions via the mobile scaphotrapeziotrapezoid and hamatotriquetral joints (radial and ulnar links). Any disruption in the circular chain of joints leads to carpal instability. An articular malalignment or malfunction of the corpus is present when the anatomical arrangement is out of alignment at rest (static instability) or their regular coor-

Table 12.3 Carpal motion patterns during ulnar inclination and radial inclination Plane

Anatomical Structure

Ulnar Inclination

Radial Inclination

Coronal

Proximal carpal row

Slides to radial side

Slides to ulnar side

Distal carpal row

Slides to ulnar side

Slides to radial side

Radial height

Increased

Decreased

Ulnar height

Decreased

Increased

Tensed ligaments

RSCL, RLTL, DRTL

ULL, UTL, TCSL, DICL

Relaxed ligaments

ULL, UTL, TCSL, DICL

RSCL, RLTL, DRTL

Proximal carpal row:

Global extension

Global flexion

Sagittal

U

Scaphoid

Extension, palmar translation

Flexion, dorsal translation

U

Lunate

Extension, palmar translation

Flexion, dorsal translation

U

Triquetrum

Distal (high) position, palmar translation

Proximal (low) position, dorsal translation

Relative flexion

Relative extension

Distal carpal rotation

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Morphometry and Function of the Carpus

dination during movement is functionally disturbed (dynamic instability). Originally, the historical term “carpal instability” (Linscheid) described only the malalignment of the central carpal column with the lunate in a dorsal or palmar intercalated segment instability rotation. Today, carpal instability denotes any disturbance in carpal equilibrium in which an abnormal joint arrangement of two or more carpal elements appears under conditions of everyday use.

Further Reading Baratz ME, Larsen CF. Wrist and hand measurements and classification schemas. In: Gilula LA, Yin Y, eds. Imaging of the Wrist and Hand. Philadelphia: Saunders; 1996:225–259. Berger RA, Crowninshield RD, Flatt AE. The three-dimensional rotational behaviors of the carpal bones. Clin Orthop. 1982;167: 303–310. Camus EJ, Millot F, Lariviere J, Raoult S, Rtaimate M. Kinematics of the wrist using 2D and 3D analysis: Biomechanical and clinical deductions. Surg Radiol Anat. 2004;26:399–410. Chamay AG. Radiolunate arthrodesis in the rheumatoid wrist. J Hand Surg. 1986; 11:771. DiBenedetto MR, Lubbers LM, Coleman CR. A standardized measurement of carpal translocation. J Hand Surg. 1990;15A:1009–1010. DiBenedetto MR, Lubbers LM, Ruff ME, Nappi JF, Coleman CR. Quantification of error in measurements of radial inclination and radialcarpal distance. J Hand Surg. 1991;16A:399–400. Fischmeister MF, Foltin E. Surface width index of the distal radius joint surface. Handchir Mikrochir Plast Chir. 1991;23:11–14. Epner RA, Bowers WH, Guildford WB. Ulna variance: The effect of wrist positioning and roentgen filming technique. J Hand Surg. 1982;7:298–305. Fisk GR. Carpal instability and the fractured scaphoid. Ann R Coll Surg Engl. 1970;46:63–76. Förstner H. The distal radio-ulnar joint. Morphologic aspects and surgical orthopedic consequences. Unfallchirurg. 1987;90:512–517. Friberg S, Lundstrom B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol Diagn. 1976;17:249–256. Garcia-Elias M, An K, Amadio PC, Cooney WP, Linscheid RL. Reliability of carpal angle determinations. J Hand Surg. 1989;14A:1017–1021. Gelberman RH, Salamon PB, Jurist JM, Posch JL. Ulnar variance in Kienbock’s disease. J Bone Joint Surg. 1975;57A:674–676. Gilula LA. Carpal injuries: Analytic approach and case exercises. Am J Roentgenol. 1979;133:503–517. Hardy DC, Totty WG, Reinus WR, Gilula LA. Posteroanterior wrist radiography: Importance of arm positioning. J Hand Surg. 1987;12A: 504–508. Jedlinski A, Kauer JM, Jonsson K. X-ray evaluation of the true neutral position of the wrist: the groove for extensor carpi ulnaris as a landmark. J Hand Surg. 1995;20A:511–512. Kapandji IA. Funktionelle Anatomie der Gelenke. Vol. 1. Obere Extremität. Stuttgart: Enke; 1984:98–281. Kapandji A. Biomechanics of the carpus and wrist. Ann Chir Main. 1987;6:147–169. Kauer JMG. The interdependence of carpal articulation chains. Acta Anat. 1974;88:481–501. Kauer JMG. Functional anatomy of the wrist. Clin Orthop. 1980;149: 9–20. Kauer JMG. The distal radioulnar joint: Anatomic and functional considerations. Clin Orthop. 1992;275:37–45. Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint. J Anat. 1970;106:539–552. Koebke J. Anatomy of the wrist joint and carpus. Unfallchirurgie. 1988; 14:74–79.

Kristensen SS, Thomassen E, Christensen F. Ulnar variance determination. J Hand Surg. 1986;11B:255–257. Larsen CF, Stigby B, Lindequist S, Bellstrom T, Mathiesen FK, Ipsen T. Observer variability in radiographic measurements of carpal bone angles on lateral radiographs of the wrist. J Hand Surg. 1991;16A: 893–898. Larsen CF, Lindequist S, Bellstrom T. Lack of correlation between ulnar variance and carpal bone angles on wrist radiographs in normal wrists. Acta Radiol. 1992;33:275–276. Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability – clinical and laboratory analysis. J Hand Surg. 1981:6A; 515–523. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic Instability of the Wrist. Diagnosis, Classification, and Pathomechanics. J Bone Surg. 1972;54A:1612–1632. Mann FA, Kang SW, Gilula LA. Normal palmar tilt: Is dorsal tilting really normal? J Hand Surg. 1992;17B:315–317. McMurtry RY, Youm Y, Flatt AE, Gillespie TE. Kinematics of the wrist. II. Clinical applications. J Bone Joint Surg. 1978;60A:955–961. Moojen TM, Snel JG, Ritt MJ, Venema HW, Kauer JM, Bos KE. Scaphoid kinematics in vivo. J Hand Surg. 2002;27A:1003–1010. Moritomo H, Goto A, Sato Y, Sugamoto K, Murase T, Yoshikawa H. The triquetrum-hamate joint: An anatomic and in vivo three-dimensional kinematic study. J Hand Surg. 2003;28A:797–805. Nattrass GR, King GJ, McMurtry RY, Brant RF. An alternative method for determination of the carpal height ratio. J Bone Joint Surg. 1994;76A:88–94. Paley D, Axelrod TS, Martin C, Rubenstein J, McMurtry RY. Radiographic definition of dorsal and palmar edges of the distal radius. J Hand Surg. 1989;14A:272–276. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg. 1982;7:376–379. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthrop. 1984;187:26–35. Peh WC, Gilula LA. Normal disruption of carpal arcs. J Hand Surg. 1996;21A:561–566. Pfirrmann CW, Theumann NH, Chung CB, Trudell DJ, Resnick D. The hamatolunate facet: Characterization and association with cartilage lesions-magnetic resonance arthrography and anatomic correlation in cadaveric wrists. Skeletal Radiol. 2002;31:451–456. Poznanski AK. Useful measurements in the evaluation of hand radiographs. Hand Clin. 1991;7:21–35. Ruby LK, Cooney WP III, An KN, Linscheid RL, Chao EYS. Relative motion of selected carpal bones: A kinematic analysis of the normal wrist. J Hand Surg. 1988;13A:1–10. Schimmerl-Metz SM, Metz VM, Totterman SM, Mann FA, Gilula LA. Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology. J Hand Surg. 1999;24A:1237–1244. Schmidt HM, Lanz U. Surgical Anatomy of the Hand. Stuttgart: Thieme; 2004. Schuind FA, Linscheid RL, AN KA, Chao EYS. A normal database of posterioranterior measurements of the wrist. J Bone Joint Surg. 1992;74A:1418–1429. Sennwald G. The Wrist. Anatomical and Pathophysiological Approach to Diagnosis and Treatment. Heidelberg: Springer; 1987. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate, Part II. J Hand Surg. 2005;30A:24–34. Taleisnik J. The Wrist. New York: Churchill Livingstone; 1985:13–38. Viegas SF, Patterson R, Peterson PD et al. The effects of various load paths and different loads on the load transfer characteristics of the wrist. J Hand Surg. 1989;14A:458–465. Viegas SF, Wagner K, Patterson R, Peterson P. Medial (hamate) facet of the lunate. J Hand Surg. 1990;15A:564–571. Weber ER. Concepts governing the rotational shift of the intercalated segment of the carpus. Orthop Clin North Am. 1984;15:193–207.

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Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapitate alignment: Criterion to establish a neutral lateral view of the wrist. Radiology. 1997;205:865–869. Yoshioka S, Okuda Y, Tamai K, Hirasawa Y, Koda Y. Changes in carpal tunnel shape during wrist joint motion. J Hand Surg. 1993;18B: 620–623. Youm Y, McMurty RY, Flatt AE, Gillespie TE. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexionextension. J Bone Joint Surg. 1978;60A:423–431.

Zanetti M, Hodler J, Gilula LA. Assessment of dorsal or ventral intercalated segmental instability configurations of the wrist: Reliability of sagittal MR images. Radiology. 1998;206:339–345. Zanetti M, Gilula LA, Jacob HA, Hodler J. Palmar tilt of the distal radius: Influence of off-lateral projection initial observations. Radiology. 2001;220:594–600.

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Postsurgical Radiography H. Krimmer, P. Hahn, R. Schmitt

Postsurgical radiography both documents and evaluates the surgical procedure performed. Following reconstructive procedures, restitution of form, fracture stabilization, the correct alignment of joints, and the position of osteosynthesis material are of primary

importance. In salvage procedures, evaluation of the defined surgical goal and the position of prostheses and osteosynthesis material have priority. Follow-up examinations assess the osseous consolidation or the integration of prostheses.

Partial Arthrodesis of the Wrist Partial arthrodesis of the wrist (Table 13.1) is carried out to eliminate joint surfaces destroyed by trauma or degenerative processes and to maintain a functionally suitable range of motion in the remaining joints (midcarpal and

radiocarpal partial arthrodesis). Arthrodesis between the scaphoid, trapezium, and trapezoid (triscaphe arthrodesis) is performed for this reason in isolated scaphotrapeziotrapezoidal (STT) osteoarthritis. In chronic

Table 13.1 Partial carpal arthrodesis and postsurgical radiographic evaluation Partial Midcarpal Arthrodesis (Four Corner Fusion) Indication for surgery

U U

SLAC wrist SNAC wrist

Partial Radiocarpal Arthrodesis (RSL Fusion, RL Fusion) U U

Radiocarpal osteoarthritis Ulnar translocation

Triscaphe Fusion U U U

Surgical principle

U U U

Postsurgical radiographic criteria

U U

U

Figure

Scaphoid resection Restoring the lunate Arthrodesis of the midcarpal joint Restoring the lunate Congruence of the proximal and distal carpal row Extra-articular position of the osteosynthesis material

U U

U

U

Carpal reduction Arthrodesis between lunate and/or scaphoid and the radius Position of the proximal carpal row Extra-articular position of the osteosynthesis material

Fig. 13.1

U U

U U

STT osteoarthritis Lunate osteonecrosis Chronic SL dissociation Arthrodesis in the STT joints Straightening of the scaphoid to about 45–60° Position of the scaphoid Extra-articular position of osteosynthesis material

Fig. 13.2

a

b Fig. 13.1 a, b Partial midcarpal arthrodesis. Kirschner wires have already been removed.

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Fig. 13.2 Triscaphe fusion for lunate osteonecrosis.

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13 Postsurgical Radiography

scapholunate (SL) dissociation and advanced lunate osteonecrosis, stabilization of the radial column of the

carpus is performed to prevent carpal collapse, realizing the preventive aspect.

Surgery of the Distal Ulna Salvage procedures of the distal end of the ulna (Table 13.2) are performed in posttraumatic or degenerative destruction of the distal radioulnar joint (DRUJ) to

Fig. 13.3 Kapandji’s procedure.

reduce pain and to improve pronosupination. In rare cases, congenital abnormalities such as Madelung’s deformity serve as indications.

Fig. 13.4 Implantation of prosthesis to replace the ulna head.

Fig. 13.5 Shortening osteotomy for positive ulnar variance with impaction syndrome.

Table 13.2 Surgery on the distal ulna and postsurgical radiographic evaluation Bower’s Hemiresection of the Ulnar Head Indication for surgery

U

Osteoarthritis of the distal radioulnar joint

Kapandij’s Procedure U

Osteoarthritis of the distal radioulnar joint

Prosthesis of the Ulnar Head U

U

Surgical principle

U

U

Hemiresection and shortening of the ulnar head if necessary Refixation of the TFCC

U

U

Arthrodesis of the distal ulna end to a level plane Segment resection of distal ulna shaft (new rotating joint)

U

U

Postsurgical radiographic criteria

U

U

Level of the ulna end in relation to the radius Impingement under load

U

U U

Figure

Fig. 13.12

Level and position of the ulna head Extent of resection Impingement under load

Fig. 13.3

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U U

Osteoarthritis of distal radioulnar joint Ulna instability after Bowers’ or Kapandji’s procedure Press-fit implantation with placement of prosthetic head at zero-level or slight minuslevel Stabilization with soft-tissue flaps Level of prosthetic head Congruent position in lateral radiograph

Fig. 13.4

Surgery for Fractures and Nonunion of the Scaphoid

Shortening of the Radius and Ulna Shortening of the radius or ulna (Table 13.3) is performed to change carpal force transmission. The posttraumatic or constitutional ulnocarpal impaction syndrome serves as an indication for resection osteotomy of the ulna. Lunate

osteonecrosis in the presence of negative ulnar variance can be treated successfully by segment excision of the distal radial shaft (shortening osteotomy) as long as osteoarthritis has not set in.

Surgery for Fractures and Nonunion of the Scaphoid Fractures in the middle third of the scaphoid (Table 13.4) are preferably stabilized by palmar screw fixation in a distal to proximal direction. Fractures in the proximal third are treated with preference by screw fixation of the fragment in a proximal to distal direction via dorsal access because of the small size of the fragment. The headless bone screw (HBS) compression allows intraosseous placement.

Table 13.3

The same is true for scaphoid nonunion (Table 13.4), for which bone graft with restoration of the shape of the scaphoid is the fundamental surgical principle. Stabilization is achieved with a screw or by osteosynthesis using special small plates. In follow-up radiographs, bony reconstruction and the integration of the trabecular bone grafts are important.

Surgery of the radius/ulna and postsurgical radiographic evaluation Shortening of Radius

Indication for surgery

U

Surgical principle

U U

U

Postsurgical radiographic criteria

U U U

Shortening of Ulna

Lunate osteonecrosis

U

Segment osteotomy of the radius shaft Adjust length of radius to zero level or slight minus level Plate osteosynthesis Neutral length of radius and ulna Closed osteotomy gap Position of osteosynthesis plates

Figure

U U

U

U U U

Ulnocarpal impaction syndrome Segment osteotomy of the shaft of the ulna Adjust length of ulna to zero level or slight minus level Plate osteosynthesis Neutral length of radius and ulna Closed osteotomy gap Position of osteosynthesis plates

Fig. 13.5

Table 13.4 Surgery on the scaphoid and postsurgical radiographic evaluation Scaphoid Fracture Indication for surgery

U

Unstable fractures Delayed union All fractures in the proximal third

U

Screw fixation

U U

Surgical principle

Scaphoid Nonunion U

U U U

Postsurgical radiographic criteria

U U U

Figure

Intraosseous position of screw(s) in all planes Screw crosses the fracture line Compression of realigned fragments

See Fig. 19.10

U U

No evidence of osseous healing

Resection of pseudarthrotic margins Spongioplasty and restitution of shape Straightening of humpback deformity Intraosseous position of screw(s) in all planes Length and alignment of scaphoid and lunate

See Fig. 20.11

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Surgery for Radius Fractures and Corrective Osteotomy of the Radius Depending on their type (Table 13.5), fractures of the distal radius section are stabilized by Kirschner wires, external fixation, or palmar or dorsal plate osteosynthesis with the goal of retaining the surgical result after open or closed reduction. The principle of osteosynthesis with palmar fixed-angle plates is to stabilize the joint even in extension fractures with an extensive dorsal comminution area without bone graft and without the inherent danger of secondary loss of the reduction result. Malunited radius fractures with shortening and malalignment of the joint surfaces (Table 13.5) are treated by osteotomy and correction of the malalignment and grafting with corticocancellous blocks. Stabilization is preferably achieved with plate osteosynthesis. In purely intraarticular malalignment, stabilization with screws or miniplates is often sufficient following correction.

a

b

Fig. 13.6 a, b Postsurgical follow-up after correction osteotomy of a malunited radius fracture.

Table 13.5 Surgery on the radius and postsurgical radiographic evaluation Primary Osteosynthesis Indication for surgery

U

Surgical principle

U

U

Postsurgical radiographic criteria Figure

U U

Loss of reduction after fracture Stabilization to prevent secondary loss of reduction Preferred stable-angle osteosynthesis Restitution of joint surface Neutral variance of radius and ulna

See Fig. 17.5

Correction Osteotomy U

U U U

U U

Extra- and intra-articular malalignment Osteotomy Spongioplasty Restitution of shape Position of joint surfaces Neutral variance of radius and ulna

Fig. 13.6

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Surgery for Carpal Instability, Dislocations, and Dislocation Fractures

Surgery for Carpal Instability, Dislocations, and Dislocation Fractures Ligamentous injuries of the proximal carpal row, perilunate dislocations, and fracture-dislocations (Table 13.6) are characterized by malalignment of the carpus. Surgical treatment consists of reduction, if necessary in combina-

tion with sutures of the extrinsic or intrinsic ligaments, and temporary transfixation of the carpal bones. Fractures of individual carpal bones are preferably stabilized by intraosseous screw osteosynthesis.

Table 13.6 Surgery for carpal injuries and postsurgical radiographic evaluation Scapholunate Dissociation Indication for surgery Surgical principle

U

U

U

Postsurgical radiographic criteria

U U

Ruptured SL ligament and carpal derangement Reduction of scaphoid and lunate Transfixation with Kirschner wires Width of SL space Size of the scapholunate angle

Perilunate Luxation U

U

U

U U

U

Figure

a

Remaining carpal malalignment after reduction Reduction of scaphoid, lunate, and triquetrum Transfixation with Kirschner wires Width of SL space Size of the scapholunate angle Alignment of lunotriquetral joint

Fig. 13.7

Perilunate FractureDislocation U U

U

U

U

U U

Always Unstable scaphoid fracture Osteosynthesis of fractured bones Reduction and transfixation of fractured/dislocated carpals Position of intraosseous screw(s) Restitution of carpal joints Alignment of carpal bones

Fig. 13.8

b

a

Fig. 13.7 a, b Temporary fixation with Kirschner wires and Mitek anchor fixation in scapholunate dissociation.

b

Fig. 13.8 a,b Osteosynthesis with HBS compression screws and temporary fixation with Kirschner wires after transscaphoid, transcapitate, perilunate fracture-dislocation (same case as in Fig. 22.9).

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13 Postsurgical Radiography

Surgical Salvage Procedures on the Phalangeal Joints Posttraumatic or degenerative destruction of the joints of the fingers and the thumb (Table 13.7) can be treated by arthrodesis or by function preserving procedures. Resection arthroplasty is the dominant procedure for trapeziometacarpal osteoarthritis. The trapezium is completely excised, and the thumb is stabilized by ligamentous reconstruction. Prostheses are the treatment of choice on the metacarpophalangeal and proximal interphalangeal joints if the extensor tendons and collateral

ligaments are intact or can be reconstructed and a sufficient bony anchor is present. Silicon prostheses are primarily used for patients with rheumatoid arthritis. For isolated posttraumatic or degenerative destruction, anatomic prostheses made of metal–polyethylene combinations, ceramic, or pyrocarbon are becoming increasingly popular. Introduction of the prosthesis with the press-fit technique without bone cement is the method of choice.

Table 13.7 Salvage procedures on the finger joints and postsurgical radiographic evaluation Resection Arthroplasty of Trapeziometacarpal Joint Indication for surgery

U U

Principle of surgery

U

U

Postsurgical radiographic criteria

U

U U

CMC I osteoarthritis STT osteoarthritis Complete resection of trapezium Ligamentous reconstruction

Complete resection of trapezium Shortening of thumb ray Osteoarthritis between scaphoid and trapezoid

Figure

Prostheses of the Metacarpophalangeal Joints U

U U U

U

U

Osteoarthritis Resection of joint surfaces Press-fit implantation Reconstruction of ligaments if necessary Correct longitudinal alignment of prosthesis Complete fixation on shaft

Fig. 13.9

Prostheses of the Proximal Interphalangeal Joints U

U U U

U

U

Osteoarthritis Resection of joint surfaces Press-fit implantation Reconstruction of extensor tendons and ligaments if necessary Correct longitudinal alignment of prosthesis Complete fixation on shaft

Fig. 13.10

a Fig. 13.9 Swanson’s arthroplasty and correction of alignment of the metacarpophalangeal joints II–V in rheumatoid arthritis.

b Fig. 13.10 a, b Prosthesis of the proximal interphalangeal joint implanted with the press-fit technique.

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Surgery of Phalangeal Fractures

Surgery of Phalangeal Fractures Intra-articular phalangeal fractures and fractures that are not stable after reduction or with malrotation (Table 13.8) are stabilized like open fractures with screws, plate osteosynthesis, or Kirschner wires. Assessment of phalangeal malrotation must be made by clinical examination.

a

b

Fig. 13.11 a, b Osteosynthesis of a subcapital fracture of metacarpal V with intramedullary wires.

Table 13.8 Surgery for phalangeal fractures and postsurgical radiographic evaluation Fractures of Metacarpal I Base Indication for surgery

Surgical principle

U

U U

Postsurgical radiographic criteria

U

U U

Figure

Always, as reduction results are not stable in plaster casts Open or closed reduction Stabilization with osteosynthesis Reconstruction of joint surface(s) Joint congruence Correct longitudinal alignment of metacarpal I

Fractures of Metacarpal Heads U

Dislocated fracture of head

Shaft Fractures of Metacarpals and Phalanges U U U

U

U

U

U

U

Closed reduction (traction and compression) Stabilization with intramedullary wires Reduction in correct longitudinal alignment Intramedullary position of wires Fracture plane bridged by wire

Fig. 13.11

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U U

U

U

Open fracture Irreducible fracture Unstable reduction Open reduction Screw or plate osteosynthesis

Reduction in correct longitudinal alignment Position and length of implants

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13 Postsurgical Radiography

Arthrodesis Arthrodesis of the carpal and phalangeal joints (Table 13.9) represents the end of therapeutic efforts and, at the price of complete loss of motion, provides a reduction in pain. Arthrodesis of the wrist and the proximal and distal interphalangeal joints is the most common of the fusions performed on the hand. Although resection of the joint surfaces and stabilization by osteosynthesis is sufficient for finger joints, arthrodesis of the wrist always requires bone grafting.

a

b

Fig. 13.12 a, b Radiocarpal arthrodesis and Bower’s procedure of the ulnar head.

Table 13.9 Arthrodesis of the joints of the hand and fingers and postsurgical radiographic evaluation Arthrodesis of the Wrist Indication for surgery

U

Surgical principle

U

U U

Postsurgical radiographic criteria

U U

U

Figure

Radiocarpal and/or midcarpal osteoarthritis Remove cartilage from joint surfaces Spongioplasty Plate osteosynthesis Position of wrist Position of osteosnythesis material Configuration in distal radioulnar joint

Arthrodesis of the Proximal Interphalangeal Joints U

U

U

U U U

Osteoarthritis Remove cartilage from joint surface Tension-band wiring, screw fixation Closure of joint space Phalangeal angle Position of osteosynthesis material

Fig. 13.12

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Arthrodesis of the Distal Interphalangeal Joints U

U

U

U U U

Osteoarthritis Remove cartilage from joint surface Intraosseous wire suture, screw fixation Closure of joint space Phalangeal angle Position of osteosynthesis material

Soft-Tissue and Callus Distractions

Soft-Tissue and Callus Distractions Callus distraction is indicated (Table 13.10) for malformations, posttraumatic growth disorder with early epiphyseal closure, and traumatic amputations. For radial clubhand, soft-tissue distraction can initially be performed prior to the corrective procedure of centralization (Table 13.10). A length discrepancy between the

radius and the ulna can be treated by callus distraction to prevent severe carpal malalignment. Distraction of metacarpal I with simultaneous deepening of the first interdigital web is an established procedure to improve function after amputation of the thumb at the level of the proximal phalanx.

Table 13.10 Soft-tissue and callus distraction and postsurgical radiographic evaluation Distraction of Metacarpal I Indication for surgery

U

Surgical principle

U U

U

Postsurgical radiographic criteria

U U

Amputation of the thumb Osteotomy Distraction fixator on metacarpal I Increase in length of 1 mm/ day to max. 4 cm Position of fixator New callus formation

Distraction of the Ulna U

U U

U U

Fig. 13.13

Osteotomy Distraction fixator on ulna

U

U

U

U

Figure

Complex malformation

Distraction of Radial Soft Tissue

Position of joint surfaces New callus formation Length in relation to radius

U

Radial clubhand (cannot be passively corrected) Fixator on metacarpal and radius Slow stretching away from radial inclination Position of the fixator

Fig. 13.14

Fig. 13.14 Distraction of the ulna shaft for ulnar clubhand (hypoplasia type).

Fig. 13.13 Distraction of metacarpal I after subtotal amputation of the thumb.

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Surgery of Traumatic Amputations Bone fixation as soon as possible after traumatic amputation is of utmost importance. Whenever possible, this involves shortening the bone where the amputation has occurred to diminish the tension on the structures to be reconnected microsurgically. In the fingers, stabilization

is preferably achieved by minimal osteosynthesis with Kirschner wires and wire sutures. Amputations at the wrist or forearm are usually treated by fixation with osteosynthesis plates, eventually in combination with external fixation.

Table 13.11 Traumatic amputations and postsurgical radiographic evaluation Forearm Amputation Indication for surgery

U

Surgical principle

U U

Postsurgical radiographic criteria

U

U

Amputation

Metacarpal Amputation U

Shorten bone Plate osteosynthesis of radius and ulna Correct longitudinal alignment Position of osteosynthesis material

Figure

U

U

U

U

Amputation Osteosynthesis with Kirschner wires Intraosseous wire suture Correct longitudinal alignment Position of osteosynthesis material

Thumb Amputation U

U

U

U

U

Amputation Osteosynthesis with Kirschner wires Intraosseous wire suture Correct longitudinal alignment Position of osteosynthesis material

Fig. 13.15

Fig. 13.15 a, b Osteosynthesis for amputation injury at the metacarpal level. a Amputation of middle- and forehand of a 16-year-old girl caused by an automatic bread slicer. b Postsurgical radiograph after replantation. Osteosynthetic stabilization with Kirschner wires and intraosseous wire sutures. Preservation of the trapeziometacarpal joint.

a

b

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Surgery of Traumatic Amputations

Further Reading Beckenbaugh RD, Linscheid RL. Arthroplasty in the hand and wrist. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol. 1. New York: Churchill Livingstone; 1993:143–187. Brockman R, Weiland AJ. Small joint arthrodesis. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol. 1. New York: Churchill Livingstone; 1993:99–111. Dailiana ZH, Malizos KN, Zachos V, Varitimidis SE, Hantes M, Karantanas A. Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid. J Hand Surg. 2006; 31A:397–404. Dick HM. Wrist arthrodesis. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol. 1. New York: Churchill Livingstone; 1993:131–142. Feldon P. Wrist fusions: Intercarpal and radiocarpal. In: Lichtman DM, ed. The Wrist and its Disorders. Philadelphia: Saunders; 1988: 446–464. Heim U, Pfeiffer KM. Periphere Osteosynthesen. 4th ed. Heidelberg: Springer; 1991. Herbert TJ. The Fractured Scaphoid. St. Louis: Quality Medical Publishing; 1990. Kalb K, Markert S. Preliminary results with Cuenod’s osteoligamentoplasty and capsulodesis for treatment of chronic scapholunate dissociation. [in German] Handchir Mikrochir Plast Chir. 2003;35:310–316.

Markiewitz AD, Stern PJ. Current perspectives in the management of scaphoid nonunions. Instr Course Lect. 2005;54:99–113. Smith DK, Baker K, Gilula LA. Radiographic features in hand surgery excluding arthroplasties. Eur J Radiol. 1990;10:85–91. Sim E, Zechner W. Computerized tomography after surgical management of scaphoid fractures and pseudarthroses with implants in place. Method and results in 15 cases. [in German] Handchir Mikrochir PlastChir. 1991;23:67–73. Swanson AB. Silicone rubber implants for the replacement of the carpal scaphoid and the lunate bones. Orthop Clin North Am. 1973;1: 299–309. Taleisnik J. The Suave-Kapandji procedure. Clin Orthop. 1992;275: 110–123. Watson HK, Ryu J, Akelman E. Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the scaphoid. J Bone Joint Surg. 1986;68A:345–349. Watson HK, Dhillon HS. Intercarpal arthrodesis. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol. 1. New York: Churchill Livingstone; 1993:113–130.

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Growth, Normal Variants, and Malformations of the Hand 14 The Growing Skeleton of the Hand

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The Growing Skeleton of the Hand A. Horwitz, G. Schindler

With reference to statistical tables, current skeletal age and expected body height can be determined with sufficient accuracy from radiographs. Both values can

be determined from the third month of life by examining a radiograph of the left hand.

Normal Development of the Skeleton of the Hand Ossification of the skeleton begins in the second fetal month and continues rapidly thereafter. Several centers of ossification develop and rapidly fuse at the diaphyses and metaphyses of the tubular bones. The first of these ossification nuclei appears in the clavicula and the upper and lower jaws. Fetal ossification is completed in the eighth to ninth fetal month of life. Under normal developmental conditions, the shafts of all tubular bones, as well as the epiphyseal nuclei of the distal femur, the proximal tibia, and the round bones (talus and calcaneus) are visible at birth. Ossification of all other epiphyses and round bones does not take place until the postfetal period. Longitudinal growth of the tubular bones parallels ossification of the epiphyses and apophyses after the

fetal period. Both processes are completed with closure of the epiphyses in puberty. Sesamoids appear at about the age of 13 years, but differ individually in the time of their appearance and in their number. In the hand, they first appear in the metacarpophalangeal joints. Somewhat later, the relatively constant sesamoids appear in the interphalangeal joints of the thumb, where they can be found in 94 % of individuals on the radial side and in 100 % on the ulnar side of the hand. Puberty begins at the time of their appearance. Besides the increase in the number of epiphyses and growth in height, there is also a change in the shape of the epiphyses, which represents skeletal development, as well as that of the entire organism.

Disturbances in Skeletal Maturation If general development is disturbed (Table 14.1), changes appear that can also be recognized in skeletal maturation. The measurement methods detailed in the following sections enable determination of skeletal age and recognition of a possible retardation or acceleration.

Table 14.1 Causes of disturbances in skeletal maturity U U U U U U U

Chromosomal abnormalities Skeletal dysplasias Endocrine disorders, early or late puberty Metabolic disorders, disorders of skeletal metabolism Malnourishment or undernourishment, vitamin deficiency Chronic inflammatory diseases Intracranial tumors

The hand, with its 28 bones (and additional 19 epiphyses), reflects general skeletal maturation (Fig.14.1). For this reason, a radiograph of the left hand is generally taken to determine skeletal maturation. The radiograph of the hand is considered a reliable indicator for maturation of other body systems and is therefore of special importance in determining the age of a child. The pattern of radioisotope uptake in scintigrams of the hand is also largely dependent on the stage of skeletal development and provides the basis for age-dependent illustrations in tables. Not only bone nuclei but also nonossified cartilage can be demonstrated in MRI. However, these two methods have not yet become part of clinical routine.

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Disturbances in Skeletal Maturation

Fig. 14.1 Summary table of skeletal age in childhood (Greulich and Pyle) sex not considered (as modified by Schmid and Moll).

newborn

3 months

3 years

7 years

6 months

4 years

9 years

13 years

1 year

1½ years

5 years

10 years

14 years

2 years

6 years

12 years

19 years

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14 The Growing Skeleton of the Hand

Legal and Forensic Considerations Occasionally determination of the skeletal age is required by the criminal investigation department or courts of law. In most cases, this information is needed to determine the age of asylum seekers or juvenile delinquents, for whom it must quickly be clarified whether juvenile criminal law is still applicable. In most countries, the judicially required degree of certainty is “probability bordering on certainty.” This indicates a probability of over

99 %, which is not achievable with a radiograph of the hand alone. Therefore, exact determination of age requires, in addition to a radiograph of the left hand, a physical and dental examination, including a panoramic film of the teeth. The radiologic medical certificate alone constitutes a decision aid for judges and public prosecutors.

Evaluation Methods in Diagnostic Imaging Age-dependent Factors

Determination of Skeletal Age Skeletal age can be determined in three ways:

Age Determination Up to Three Months The hands of newborns and infants have neither epiphyseal nor carpal ossification nuclei. Therefore, for determination of the skeletal age in the first three months of life, a radiograph of the lower leg with knee and ankle is taken because the ossification nuclei in the proximal epiphysis of the tibia, the calcaneus, and the talus are physiologically evident at birth. These ossification nuclei can also be demonstrated with ultrasonography in newborns (Fig.14.2).

Age Determination after the Third Month of Life From this time on, the standard method for determining skeletal age is by examining a radiograph of the left hand, which is easy to obtain (Fig.14.3). Radiation exposure: a voltage of 30−45 kV, a tube current of 3−6 mAs, class 400 intensifying screens, a small focus, and no scattered radiation grid; cover the child’s trunk with a lead apron and turn it away from the examining table.

Atlas of Greulich and Pyle This atlas contains age standards between the third month of life and the age of 17 years for the skeleton of the left hand; the illustrations are presented according to sex, with 31 standard examples for boys and 29 for girls. (In the modified version in Figure 14.1, sex differences are not taken into consideration.) The atlas also includes lists of the age of each individual bone nucleus. Developmental details of the bone nuclei are briefly explained in a separate section. The atlas is based on a normal population of Caucasian children and young persons in the United States. To determine skeletal age, first the radiograph of the hand is compared with the picture in the atlas illustrating the hand of someone of the same age and sex. After comparison also with pictures of hands in the next older and younger age categories, the illustration is chosen that is most like the radiograph being evaluated (see Table 14.2). Fig. 14.2 a, b Ultrasonographic evidence of ossification nuclei in a mature female newborn at the age of 2 weeks.

condyle of the femur

head of the tibia

a Ossification nuclei at the distal epiphysis of the femur and the proximal epiphysis of the tibia.

fibula

talus

calcaneus

b Ossification nuclei of the talus and calcaneus.

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Evaluation Methods in Diagnostic Imaging

Fig. 14.3 a, b Pathological skeletal age in a boy with von Recklinghausen disease.

a At a chronological age of 7 years the skeletal age is that of a 4½- to 5-year-old child (retardation). An optic glioma with disorder of the hypothalamus–hypophysis axis was confirmed at the time the radiograph was taken.

b After substitution with human growth hormone (HGH therapy) the skeleton matured rapidly, resembling the skeletal age of a 12½- to 13-year-old at the chronological age of 9 years and 4 months (acceleration).

Occasionally the development of the bone nuclei is dissociated as a result of different stages of maturity. Then it is recommended to separately determine skeletal age of the long (radius and ulna) and short tubular bones, as well as the carpals, and finally to calculate the actual skeletal age by averaging the individual results. The upper and lower limits of normal skeletal development can be seen in Table 14.2

change during maturation. Three scoring systems are available for determination of skeletal age: U RUS = radius, ulna, short bones (carpals and phalanges of fingers I, III, and V), U Carpal Index: all carpals, U 20 ossicles: a combination of RUS and the Carpal Index.

Atlas of Thiemann and Nitz This atlas for the determination of skeletal age, which was published in 1986, lists standards of children from the former German Democratic Republic and represents middle European norms. The methodology is the same as that for the Greulich and Pyle atlas.

Methods According to Tanner, Whitehouse et al. The method known as “TW 2” is the version modified in 1975 of the original publication from 1962. The individual ossification nuclei are not analyzed according to their size but according to their shape and tendencies to

Table 14.2 Upper and lower limits of normal skeletal development (according to Garn) Age in Years

1 ± 2 Standard Deviations from Normal Development

Boys

Girls

Boys and Girls

0–1

0–1

± 3–6 months

2–3

3–4

± 1–1.5 years

6–10

7–11

± 2 years

12–13

13–14

± over 2 years

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14 The Growing Skeleton of the Hand

Determination of the Prospective Mature Body Height Skeletal maturation correlates closely with growth in height. Statistical methods that describe the relationships between these two parameters can therefore provide an approximation of the prospective mature height from the current height. This method is clinically relevant, especially when there are deviations from normal height. Two methods are available.

Method According to Bayley and Pinneau This method is applied to healthy individuals together with the determination of skeletal age according to Greulich and Pyle. The prospective height is determined with tables based on skeletal age. The chronological skeletal age is categorized into “average,” “accelerated,” and “retarded.” It should be noted that the method is not reliable with a retardation or acceleration of two years. The expected full height is calculated by the rule of three from the current height. Proportional deviations are provided. The accuracy of the procedure increases with the child’s age. This simple method has gained acceptance in the clinical routine because of its practicability.

Method According to Tanner, Whitehouse et al. This calculation is based on a regression equation in which the parameters skeletal age (according to the RUS score), chronological age, current height, menarche in girls, and a constant representing the parents’ heights, are included. The individual parameters are multiplied by factors depending on the chronological age and then added (or subtracted). The range of deviation and the predictability have been reported. This method is generally superior to that of Bayley and Pinneau, but it should be reserved for special cases (extreme retardation or acceleration or for tall families) because of the complicated computation involved.

Further Reading Acheson RM, Fowler G, Fry El et al. Studies in the reliability of assessing skeletal maturation from X-rays. I. Greulich-Pyle atlas. Hum Biol. 1963;37:317–349. Bayley N, Pinneau S. Tables of predicting adult height from skeletal age: Revised for use with the Greulich and Pyle hand standards. J Pediat. 1952;40:423–432. Birkner R. Das typische Röntgenbild des Skeletts. Munich: Urban & Schwarzenberg; 1977. Graham CB. Assessment of bone maturation: Methods and pitfalls. Radiol Clin North Am. 1972;10:185–202. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist. 2nd ed. Stanford: Stanford University Press; 1959. Groell R, Lindbichler F, Riepl T, Gherra L, Roposch A, Potter R. The reliability of bone age determination in central european children using the Greulich and Pyle method. Br J Radiol. 1999;72:461–464. Gross GW, Boone JM, Bishop DM. Pediatric skeletal age: Determination with neural networks. Radiology. 1995;195:689–695. Harris EF, Weinstein S, Weinstein L, Poole AE. Predicting adult stature: A comparison of methodologies. Ann Hum Biol. 1980;7:225–234. Hubbard AM, Meyer JS, Davidson RS, Mahboubi S, Harty MP. Relationship between the ossification center and cartilaginous anlage in the normal hindfoot in children: Study with MR imaging. Am J Roentgenol. 1993;161:849–853. Milner GR, Levick RK, Kay R. Assessment of bone age: A comparison of the Greulich and Pyle, and the Tanner and Whitehouse methods. Clin Radiol. 1986;37:119–121. Schmid F. Pädiatrische Radiologie. Heidelberg: Springer; 1973. Schmid F, Moll H. Atlas der normalen und pathologischen Handskelettentwicklung. Heidelberg: Springer; 1960. Schmeling A, Kaatsch HJ, Marré B et al. Empfehlungen für die Altersdiagnostik bei Lebenden im Strafverfahren. Rechtsmedizin. 2001; 11:1–3. Tanner JM, Whitehouse RH, Cameron N, Marshall WA, Healy MJR, Goldstein H. Assessment of Skeletal Maturity and Prediction of Adult Height (TW2 Method). New York: Academic Press; 1983. Tanner JM, Gibbons RD. Automatic bone age measurement using computerized image analysis. J Pediatr Endocrinol. 1994;7: 141–145. Thiemann HH, Nitz I. Röntgenatlas der normalen Hand im Kindesalter. Leipzig: VEB Georg Thieme; 1986. Yarbrough C, Habicht JP, Klein RE, Roche AF. Determining the biological age of the preschool child from a hand-wrist radiograph. Invest Radiol. 1973;8:233–243. Zachmann M. Voraussage der Erwachsenengröße. Extracta Pediat. 1981;5:361–368.

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Normal Variants of the Skeleton and the Soft Tissues of the Hand R. Schmitt, G. Schindler

Nonpathologic variants of the skeleton of the hand include accessory sesamoid bones, coalescences and divisions of the carpal bones, and accessory bones. In contrast to malformations, these are not considered diseases and cause no functional disturbance. Diagnostically, these findings should always be differenti-

ated from posttraumatic conditions. The most important variants of soft tissues of the hand are aberrant or accessory muscles. These are often asymptomatic and are discovered incidentally on MR images or during surgery.

Normal Variants of the Skeleton of the Hand Sesamoid Bones Sesamoids are located on the palmar side of the metacarpophalangeal and the distal interphalangeal joints. Their prevalence depends on their location, as listed in Table 15.1.

Coalescence of the Carpals Coalescence here refers to fusion of two carpal bones. Idiopathic coalescences, in which mostly two bones in the same carpal row are congenitally fused, are differentiated from postinflammatory or posttraumatic forms,

Table 15.1 Frequency of sesamoid bones in the hand (according to Birkner) Localization

Frequency (%)

Sesamoid radial I

95

Sesamoid ulnar I

100

Sesamoid radial II

50

Sesamoid radial III

2

Sesamoid radial IV

2

Sesamoid ulnar IV

10 MHz) and a high level of skill and experience on the part of the examiner. The various forms of tenosynovitis, articulosynovitis, and extra-articular manifestations in the rheumatic hand can be differentiated with the use of US: U Inflammatory tenosynovial lesions appear as canalicular hypoechoic structures around the hyperechoic tendons (Fig. 36.8 c, d). In the examination from the palmar side, the flexor tendons can be clearly seen at the height of the fingers and the carpal canal. In the presence of carpal tunnel syndrome, exudative and primarily proliferating forms of tenosynovitis can be differentiated ultrasonographically. Further diagnos-

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36 Rheumatoid Arthritis

U

flammatory tissue appears hypoechoic, and often the joint capsule bulges significantly. Extraarticular rheumatic manifestations, like pannus in the triangular fibrocartilage complex (Fig. 38.8 a) and subcutaneous rheumatic nodules (Fig. 38.8 d), can be demonstrated ultrasonographically.

Computed Tomography Fig. 36.7 Tendography in rheumatoid arthritis. Inflammatory lesions in the flexor tendon sheath with ganglionic saccular protrusions.

U

tic criteria of the inflammatory carpal tunnel syndrome are flattening of the median nerve and a palmar bulging of the flexor retinaculum. US examination from the dorsum of the hand objectively visualizes tenosynovitis of the extensor tendons, on which ganglionic protrusions on the tendon sheath can be seen. An important function of US in imaging rheumatoid arthritis is the identification of ruptured tendons (Fig. 29.10 a), which often involve the extensor tendons, and, in this case, especially the extensor pollicis longus tendon. Owing to their superficial position, articulosynovitis of the metacarpophalangeal and proximal interphalangeal joints is particularly suited for assessment with US (Fig. 36.8 c). When the synovium is affected, the in-

Osseous destruction in rheumatoid arthritis can be reliably identified in high-resolution CT by acquiring thin axial slices of 0.5–1 mm and by computing coronal and sagittal MPR images. Soft-tissue changes, like joint effusions, can also be visualized. Both the osseous and the soft-tissue components of carpal tunnel syndrome are best depicted with axial CT slices (Chapter 46). With inflammatory carpal tunnel syndrome, effusions in the tendon sheaths and phalangeal flexors are remarkably well defined. However, the excellent information obtained with projectional radiography, MRI and US make valid indications for CT imaging of rheumatic joints rare.

Magnetic Resonance Imaging All tissues affected by rheumatoid arthritis can be visualized reliably in MRI. Characteristics of MRI are the excellent contrast seen in inflamed soft tissues (e. g., synovial membrane, pannus, joint effusion, joint capsule), the high accuracy in identifying inflammatory edema, and

Fig. 36.8 a–d US findings in rheumatoid arthritis. A 49-year-old woman with a 22-year disease history. Examination with a 13 MHz probe.

a Hypoechoic pannus (asterisks) in the triangular fibrocartilage complex. Longitudinal scan at the ulnar carpus.

b Synovitis and ulnar dislocation of the extensor tendon II (arrows). Cross-section from the dorsum of the hand at the level of the metacarpal (MC) heads.

c Hypoechoic thickening of the tendon sheath of the flexor tendons II (FDS, FDP) in synovitis with some ganglionic saccular protrusions. Articulosynovitic bulging on the metacarpophalangeal (MCP) joint. Palmar longitudinal scan along the index finger.

d Subcutaneous rheumatoid nodule (asterisk) on the flexor side of the third middle phalanx III (MP) and synovitis of the flexortendon sheath. Palmar longitudinal scan. DP = distal phalanx.

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Special Forms of Rheumatoid Arthritis

the estimation of increased perfusion in the inflamed tissue based on the degree of enhancement after intravenous administration of gadolinium. MRI and US are increasingly applied in addition to conventional radiography in the evaluation of rheumatic arthritis. Since no standardized indications for imaging of rheumatoid arthritis have yet been formulated, MRI is limited at present to the indications listed in Table 36.5, which apply to selected patients. Table 36.6 presents an examination protocol for MRI of rheumatic arthritis affecting the carpus. By reducing the slice thickness to 2 mm, the recommended sequences can also be applied to the metacarpophalangeal and proximal interphalangeal joints. Important prerequisites are the administration of a gadolinium-containing contrast agent and the use of fat-suppressed sequences. The following MRI phenomena in the rheumatic hand can be observed in the synovium, the subchondral bone, the articular cartilage, and the other periarticular soft tissues: U Noninflamed synovium, which consists of several cell layers, usually cannot be visualized in MR images. Rheumatoid arthritis, however, displays synovial proliferation and an increase in thickness, which appears as pannus, when the synovium has proliferated to such an extent that it covers the articular cartilage and infiltrates the subchondral bone. Proliferative synovial tissue appears hypointense in plain T1-weighted sequences (Fig. 36.9 b). In T2-weighted sequences, the signal intensity depends on the inflammatory activity and is hyperintense during an acute episode (Fig. 36.9 a). In the chronic stage, it displays intermediate signal intensity. A bulge in the synovial membrane caused by pannus (“bulking”) is characteristic. U Demarcation of synovial proliferation from neighboring effusions in joints and tendon sheaths, as well as from concomitant soft-tissue edema, is not always possible in plain T1- and T2-weighted sequences. As described in the sequence protocol in Table 36.6, tissue differentiation is possible more reliably after intravenous application of gadolinium, which leads to increased signal intensity in the synovium and pannus (Figs. 36.9 c, 36.10 c). Even small effusions become visible. These are hyperintense in T2-weighted se-

Table 36.5 Indications for MRI in rheumatoid arthritis additionally to radiography U

U

U

U

U

Suspicion of early arthritic manifestation when radiography is unremarkable Determination of the inflammatory activity under pharmacological treatment Preoperative localization of pannus to plan surgical synovectomy

quences and hypointense in T1-weighted sequences, on which a slight increase in signal intensity can also be seen in the joint effusion resulting from diffusion of contrast medium from the hypervascularized synovia into the joint space. It is possible to identify bone-marrow infiltration at the level of the bare areas (not covered with articular cartilage) even at a very early stage of rheumatoid arthritis with MRI. The inflammatory rheumatoid process is visualized with the following contrast ratios: – A T2-weighted sequence with fat saturation demonstrates the acutely inflamed pannus as hyperintense, the chronic stage as intermediately intense, and the non-edematous bone marrow as dark (Fig. 36.9 a). – A plain T1-weighted sequence clearly differentiates the hypointense inflammatory tissue from the hyperintense fatty bone marrow (Fig. 36.9 b). – A fat-saturated, T1-weighted sequence provides significantly better contrast differences in the inflamed tissues after intravenous administration of gadolinium (Fig. 36.9 c). – This MRI protocol allows identification of infiltrative and proliferative pannus manifestation even at initial stages when conventional radiographs remain unremarkable. The current inflammatory activity of rheumatoid arthritis can be determined by the increase in signal intensity following administration of the contrast agent. The maximal synovial enhancement is reached after about 1.5–2 minutes. The contrast enhancement, which may exceed the base values of plain MRI in the range of 25–150 %, allows differentiation between fibrous, intermediately vascularized, and hypervascu-

Table 36.6 MRI sequence protocol for rheumatoid arthritis of the carpus Type of Sequence

Orientation

Slice Thickness/Slice Gap

Number of Slices

Contrast Agent

T2*-w GRE

Axial

3 mm/10–20 %

20

No

PD-w FSE fs

Coronal

3 mm/0 %

12

No

T1-w SE

Coronal

3 mm/0 %

12

No

T1-w SE fs

Coronal

3 mm/0 %

12

Yes

T1-w SE

Sagittal

3 mm/10–20 %

15

Yes

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a

b

c

Fig. 36.9 a–c MRI findings in rheumatoid synovitis of the carpus. a The PD-weighted FSE sequence with fat saturation displays c After administration of contrast medium, the fat-saturated hyperintense inflammatory tissue around the triquetrum, T1-weighted SE sequence shows synovial enhancement not which is infiltrated at the proximal side. only at the triquetrum but also at the ulnar styloid process, at b The plain T1-weighted SE sequence shows erosions at the the scaphoid, in the distal radioulnar joint, and along the triquetrum and at the distal scaphoid pole. Extensive bulking radioscaphocapitate ligament. caused by thickened synovium.

larized pannus (Table 36.7). With these quantifiable parameters an attempt can be made to classify the rheumatoid disease process into a more active destructive or an inactive fibrous stage. It should be borne in mind that the degree of pannus vascularization does not always correlate well with the clinical appearance. A current objective of several scientific studies is the individual, specific volumetric measurement of the contrastenhanced pannus in a selected finger joint as a representative “test region” of systemic rheumatoid disease. U In rheumatoid arthritis, concomitant bone-marrow edema can almost always be seen in T2-weighted sequences. In MRI, sympathetic bone-marrow edema can be distinguished from inflammatory bone-marrow infiltration (rheumatic osteitis) with the use of a contrast-enhanced T1-weighted sequence. There is only a loose correlation between bone-marrow edema identified in MRI and signs of periarticular osteopenia in projection radiography.

Table 36.7 Inflammatory activity of the synovium corresponding to contrast enhancement in MRI (modified according to Jevtic) Inflammatory Activity

Degree of Contrast Enhancement

Destructively active

Inhomogeneously hypervascularized

Moderately active

Homogeneously vascularized

Fibrous and inactive

Not or only slightly vascularized

U

U

“Chondromalacia” caused by synovitis leads to a change in the signal intensity of the articular cartilage in MRI. In T2- or T2*-weighted sequences, there is a focal increase in signal intensity at the site of the initial cartilage damage (Fig. 36.11 b) and a decrease in signal intensity in T1-weighted sequences. Because of the thin cartilage layer in the carpal and phalangeal joints, early chondromalacia is difficult to detect. In later stages, intrachondral contrast enhancement confirms cartilaginous infiltration by synovitic and pannus tissue (Fig. 36.11 a). A decrease in height and irregular surface contours of the articular cartilage soon follow. Rheumatic destruction of the carpal ligaments and tendons can be visualized in MR images. In addition to the predisposed triangular fibrocartilage complex, including the sheath of the extensor carpi ulnaris tendon, synovitic erosions of the intrinsic and extrinsic ligaments are regularly observed (Figs. 36.9 c, 36.11 a). Intense enhancement is seen at these sites after administration of gadolinium. During the course of the rheumatoid inflammation, the well-vascularized radioscapholunate ligament (Testut’s ligament) apparently plays a key role, as rapidly progressing destruction of the palmar extrinsic ligaments (radioscaphocapitate, radiolunotriquetral, ulnolunate, and ulnotriquetral) and slippage of the carpus to the ulnar side (ulnar translocation) occur when this ligaments is initially affected. Clinically, a rheumatic rupture of the tendon of the extensor pollicis longus muscle is sometimes difficult to differentiate from arthritis in the metacarpophalangeal joint of the thumb or an irritation of the posterior interosseous nerve. In this case, MRI or US can undoubtedly help to clarify the situ-

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Special Forms of Rheumatoid Arthritis

a

a

b

b

c Fig. 36.10 a–c Diagnostic value of MRI in early stages of rheumatoid arthritis. a Despite severe clinical inflammatory symptoms, radiographs show only periarticular osteopenia of the metacarpophalangeal joints II–IV. No erosions are present. b The plain T1-weighted SE sequence reveals pannus infiltration in the metacarpal heads II and III on the radial sides at the level of the bare areas, as well as extensive articulosynovitis. c After administration of gadolinium, there is strong enhancement of the intraosseous and intra-articular inflammatory areas. (Courtesy of R. Scheck, MD, Agatharied.)

Fig. 36.11 a, b Rheumatoid arthritis affecting ligaments and the articular cartilage. a Contrast-enhanced T1-weighted SE sequence with fat-saturation with multiple foci of erosive synovitis. Focal contrast enhancement at the scapholunate ligament and in the articular cartilage of the radioscaphoid joint compartment (arrow). b The plain T2*-weighted GRE sequence shows massive synovitis in the slightly subluxated distal radioulnar joint and in the ECU tendon sheath. Increased signal intensity in the articular cartilage of the ulna head as a sign of chondropathy (arrow).

ation. Rheumatoid arthritis predominately affects the extensor tendons, but can also damage the flexor tendons (Fig. 36.12). A complete tendon rupture can be assessed in axial T2*-weighted GRE sequences by the presence of an empty tendon sheath.

Fig. 36.12 Rupture of the extensor tendon III and ganglionic tenosynovitis in rheumatoid arthritis. Cystic, mutilating form of rheumatoid arthritis. The fat-saturated T1-weighted SE sequence following application of gadolinium reveals that the ruptured extensor tendon has retracted to the metacarpophalangeal joint (arrow). Palmar dislocation of the proximal phalanx. The flexor-tendon sheath shows massive ganglionic saccular protrusions at the level of the middle and distal interphalangeal joints.

Contrast-enhanced MRI has a very high sensitivity (unanimously reported at 100 % in the literature) in providing early evidence of arthritic synovial proliferation in the diagnosis of rheumatoid arthritis, but the specificity of MRI (70 %) is low. Therefore, classification of inflammatory joint disease can only be made synoptically according to clinical parameters and the distribution pattern of the affected joints, and with conventional radiographic findings.

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36 Rheumatoid Arthritis

Radiographic Classification of Stages of Rheumatoid Arthritis The temporal rate of joint destruction correlates closely with the course and severity of disease. The main attempts to classify rheumatoid arthritis into stages are discussed below. U The radiographic stages in the mixed clinical-radiographic classification by Steinbrocker et al. (American Rheumatism Association) are provided in Table 36.8. In this classification, the gap between stages II and III is obviously large. U Sharp et al. describe a scoring method for evaluation of each individual joint of the hand. This method evaluates the number of erosions on each joint and the degree of narrowing of the joint space. There is a close correlation between the radiographic lesions and the clinical signs of inflammation, as well as the anti-IgE antibody titers. U Larsen et al. introduced a semiquantitative evaluation technique using standard reference films and grading joint destruction with scores from 0 to 5. Except for the carpus, the individual joints of the hand are evaluated separately. The grading scale assesses erosions, narrowing of the joint space, soft-tissue swelling, and periarticular osteopenia of each individual joint (Table 36.9). Sharp’s and Larsen’s methods have been repeatedly modified and simplified. Recently, evaluation of only the carpal, metacarpophalangeal, and proximal interphalangeal joints has been recommended because they demonstrate a reasonable correlation with the clinical symptoms. In Larsen’s classification, the transition from grade III to grade IV is very wide. Sharp’s technique is more sensitive than Larsen’s, but takes more time in evaluation. U A more recent classification into stages was made by Schacherl, who provides a wider differentiation, especially between mild and moderately severe articular lesions, by introducing six stages. Schacherl differentiates 12 basic radiographic types of rheumatoid arthritis, which essentially refer to radiographic signs of osseous destruction. U Simmen and Huber functionally differentiate three basic types of rheumatoid arthritis according to a primarily surgical viewpoint (Table 36.10).

Table 36.8 Steinbrocker’s radiographic classification of rheumatoid arthritis into stages Stage

Radiographic Signs

I

Osteoporosis, no erosions

II

Osteoporosis, slight narrowing of the joint space or subchondral bone destruction

III

Osteoporosis, destruction of the articular cartilage and extensive bone destruction

IV

Osseous ankylosis in existing osteoporosis and severe bone destruction

Table 36.9 Larsen’s grading of radiographic signs in rheumatoid arthritis Grade

Radiographic Signs

0

Definitely no pathologic finding

I

Unspecific pathologic findings

II

Mild, but certain destructive lesions

III

Moderate destructive lesions

IV

Severe destructive lesions

V

Mutilating joint destruction

Table 36.10 Surgical classification of rheumatoid arthritis by Simmen and Huber Type

Radiographic Signs

I

Ankylosing form

II

Rheumatoid arthritis with secondary osteoarthritis

III

Rheumatoid arthritis with disintegration

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Therapeutic Options

Differential Diagnosis U

U

U

Rheumatoid surface erosions at the carpal joints should not be confused with physiologic articular notches and depressions (see Fig.15.12). These have continuous, sharp margins and do not interrupt the subchondral bone plate. Older erosions smoothed by osteoarthritis sometimes have similar osteosclerotic margins. Differential-diagnostic problems can arise with an atypical beginning of rheumatoid arthritis in case of a monoarticular or oligoarticular course. In such cases, differentiation from seronegative spondylar-

U

thropathies, bacterial arthritis, villonodular synovitis, gouty arthritis, CPPD deposition disease, articular chondromatosis, and, rarely, malignant or benign synovial tumors can be difficult. These problems, however, usually do not exist in polyarticular disease. In the polyarticular disease course, differentiation from psoriatic arthritis, Reiter syndrome, and multilocular osteoarthritis is generally not difficult. The same is true for affliction of the peripheral joints in Marie–Strümpell disease (ankylosing spondylitis).

Therapeutic Options With the goal of reducing pain and inflammatory symptoms and maintaining joint function, conservative (pharmacologic, physiotherapeutic, physical, ergotherapeutic), and surgical forms of therapy are differentiated. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, and indomethacin, are the drugs of first choice, whereas COX-2 inhibitors are used for patients with such risks as history of ulcers and polymorbidity. The basic pharmacologic therapies for early forms of rheumatoid arthritis with mild symptoms are antimalarials, oral gold, and sulfasalazine, and, with more obvious disease activity, methotrexate. If these therapies fail and the disease is highly aggressive, antiTNF-¥ (infliximab) is administered. Long-term treatment with steroids is initiated when basic therapy is insufficiently effective. Intra-articular application of steroids and radiosynoviorthesis are forms of local therapy. In the early phase of rheumatoid arthritis, synovectomy or bursectomy can be performed. In the late phase, prosthetic joint replacement may be indicated.

Further Reading Ansell BM, Kent PA. Radiological changes in juvenile chronic polyarthritis. Skeletal Radiol. 1977;1:129–134. Backhaus M, Kamradt T, Sandrock D et al. Arthritis of the finger joints. Arthritis Rheum. 1999;42:1232–1237. Beckers C, Ribbens C, Andre B et al. Assessment of disease activity in rheumatoid arthritis with (18)F-FDG PET. J Nucl Med. 2004;45: 956–964. Boutry N, Hachulla E, Flipo RM, Cortet B, Cotten A. MR imaging findings in hands in early rheumatoid arthritis: Comparison with those in systemic lupus erythematosus and primary Sjogren syndrome. Radiology. 2005;236:593–600. Cimmino MA, Innocenti S, Livrone F, Magnaguagno F, Silvestri E, Garlaschi G. Dynamic gadolinium-enhanced magnetic resonance imaging of the wrist in patients with rheumatoid arthritis can discriminate active from inactive disease. Arthritis Rheum. 2003;48: 1207–1213. Dihlmann W. Röntgenuntersuchungsmethodik bei rheumatischen Gelenkerekrankungen. Fortbild. Klin Rheumatol. 1976;4:161–172.

Fischer E. Low kilovolt radiography. In: Resnick D, Niwayama G, eds. Diagnosis of Bone and Joint Disorders. Philadelphia: Saunders; 1981:346–373. Fornage BD. Soft-tissue changes in the hand in rheumatoid arthritis: Evaluation with US. Radiology. 1989;173:735–737. Gasson J, Gandy SJ, Hutton CW, Jacoby RK, Summers IR, Vennart W. Magnetic resonance imaging of rheumatoid arthritis in the metacarpophalangeal joints. Skeletal Radiol. 2000:29:324–334. Giovagnoni A, Valeri G, Burroni E, Amici F. Rheumatoid arthritis: Follow-up and response to treatment. Eur J Radiol. 1998;27:25–34. Haavardsholm EA, Ostergaard M, Ejbjerg BJ et al. Reliability and sensitivity to change of the OMERACT rheumatoid arthritis magnetic resonance imaging score in a multireader, longitudinal setting. Arthritis Rheum. 2005;52:3860–3867. Huh YM, Suh JS, Jeong EK et al. Role of inflamed synovial volume of the wrist in redefining remission of rheumatoid arthritis with gadolinium-enhanced 3D-SPGR MR imaging. J Magn Reson Imaging. 1999;10:202–208. Jevtic V, Watt I, Rozman B, Kos-Golja M, Demsar F, Jarh O. Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondylarthritis demonstrated by contrastenhanced (Gd-DTPA) magnetic resonance imaging. Skeletal Radiol. 1995;24:351–355. Kellgren JH, Jefrey M.R, Ball J. Atlas of Standard Radiographs of Arthritis. Oxford: Blackwell Scientific Publications; 1963. Klarlund M, Ostergaard M, Lorenzen I. Finger joint synovitis in rheumatoid arthritis: quantitative assessment by magnetic resonance imaging. Rheumatology. 1999;38:66–71. König H, Sieper J, Wolf KJ. Rheumatoid arthritis: Evaluation of hypervascular and fibrous pannus with dynamic MR imaging enhanced with Gd-DTPA. Radiology. 1990;176:473–477. Kushner DM, Braunstein EM, Buckwalter KA. Carpal instability in rheumatoid arthritis. J Canad Assoc Radiol. 1993;44:291–296. Larsen A. Radiological grading of rheumatoid arthritis. Scand J Rheumatol. 1973;2:136–138. Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn. 1977;18:481–491. Lingg G, Herrmann K. Möglichkeiten der Computertomographie in der Rheumatologie. Akt Rheumatol. 1993;18:181–193. Lingg G, Keller E. Gelenkerkrankungen. In: Reiser M, Peters PE, eds. Radiologische Differentialdiagnose der Skeletterkrankungen. Stuttgart: Thieme; 1995:325–428. Martel W, Hayes JT, Duff IF. The pattern of bone erosion in the hand and wrist in rheumatoid arthritis. Radiology. 1965;84:204–214.

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McCall IW, Sheppard H, Haddaway M, Park WM, Ward DJ. Gallium-67 scanning in rheumatoid arthritis. Br J Radiol. 1983;56:241–243. McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N. Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years. Arthritis Rheum. 2005;52:744–751. Miehlke W. Rheumatoide Arthritis. Diagnose und Therapie. Basel: Eular; 1994. Nägele M, Kunze V, Koch W et al. Rheumatoid arthritis of the wrist. Dynamic Gd-DTPA enhanced MRT. Fortschr Röntgenstr. 1993;158: 141–146. Nakahara N, Uetani M, Hayashi K, Kawahara Y, Matsumoto T, Oda J. Gadolinium-enhanced MR imaging of the wrist in rheumatoid arthritis: Value of fat suppression pulse sequences. Skeletal Radiol. 1996;25:639–647. Newman JS, Laing TJ, McCarthy CJ, Adler RS. Power Doppler sonography of synovitis: Assessment of therapeutic response-preliminary observations. Radiology. 1996;198:582–584. Norgaard F. Earliest roentgenological changes in polyarthritis of the rheumatoid type: Rheumatoid arthritis. Radiology. 1965;85: 325–329. Ostergaard M, Stoltenberg M, Lovgreen-Nielsen P, Volck B, Jensen CH, Lorenzen I. Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatoid arthritis and osteoarthritis: Comparison with the macroscopic and microscopic appearance of the synovium. Arthritis Rheum. 1997;40:1856–1867. Palmer WE, Rosenthal DI, Schoenberg OI et al. Quantification of inflammation in the wrist with gadolinium enhanced MR imaging and PET with 2-[F-18]-fluoro-2-deoxy-D-glucose. Radiology. 1995; 196:647–655. Perry D, Stewart N, Benton N et al. Detection of erosions in the rheumatoid hand. A comparative study of multidetector computerized tomography versus magnetic resonance scanning. J Rheumatol. 2005;32:256–267. Peterfy CG. MRI of the wrist in early rheumatoid arthritis. Ann Rheum Dis. 2004;63:473–477. Reiser MF, Bongartz GP, Erlemann R et al. Gadolinium-DTPA in rheumatoid arthritis and related diseases: First results with dynamic magnetic resonance imaging. Skelatal Radiol. 1989;18:591–597. Resnick D, Niwayama G. Rheumatoid arthritis and related diseases. In: Resnick D, Niwayama G, eds. Diagnosis of Bone and Joint Disorders. Philadelphia: Saunders; 1981:850–1149.

Rominger MB, Bernreuter WK, Kenney PJ, Morgan SL, Blackburn WD, Alarcon GS. MR imaging of the hands in early rheumatoid arthritis: Preliminary results. Radiographics. 1993;13:37–46. Schacherl M. Radiologischer Atlas rheumatischer Erkrankungen. Teil I. Hand. In: Mathies H, Wagenhäuser FJ, eds. Compendia Rheumatologica. Basel: Eular; 1983. Senac MO, Beutsch D, Bernstein BH et al. MR imaging in juvenile rheumatoid arthritis. Am J Roentgenol. 1988;158:873–878. Sharp JT, Lidsky MD, Collins LS, Moreland J. Methods of scoring the progression of radiologic changes in rheumatoid arthritis. Arthritis Rheum. 1971;14:706–720. Simmen BR, Huber H. The wrist joint in chronic polyarthritis—a new classification based on the type of destruction in relation to the natural course and the consequences for surgical therapy. Handchir Mikrochir Plast Chir. 1994;26:182–189. Steinbrocker O, Traeger GH, Batterman RC. Therapeutic criteria in rheumatoid arthritis. J Am Med Assoc. 1949;140:659–662. Sugimoto H, Takeda A, Kano S. Assessment of disease activity in rheumatoid arthritis using magnetic resonance imaging: Quantification of pannus volume in the hands. Br J Radiol. 1998;37:854–860. Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: Prospective study of the effectiveness of MR imaging for diagnosis. Radiology. 2000;210:569–575. Swen WA, Jacobs JW, Hubach PC, Klasens JH, Algra PR, Bijlsma JW. Comparison of sonography and magnetic resonance imaging for diagnosis of partial tears of the finger extensor tendons in rheumatoid arthritis. Rheumatology. 2000:39:55–62. Tehranzadeh J, Ashikyan O, Dascalos J, Dennehey C. MRI of large intraosseous lesions in patients with inflammatory arthritis. Am J Roentgenol. 2004;183:1453–1463. Terslev L, Torp-Pedersen S, Savnik A et al. Doppler ultrasound and magnetic resonance imaging of synovial inflammation of the hand in rheumatoid arthritis: A comparative study. Arthritis Rheum. 2003;48:2434–2441. Yulish BS, Liebermann JM, Newman AJ, Bryan PJ, Mulopulos GP, Modic MT. Juvenile rheumatoid arthritis: assessment with MR imaging. Radiology. 1987;165:149–152.

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Seronegative Spondylarthropathies S. Spindler-Thiele, A. Staebler, G. Lingg

Besides rheumatoid arthritis in children and adults, there are a number of seronegative polyarthritic diseases with involvement of the axial skeleton whose pathogenesis and terminology are still indefinite. Among these are psoriatic arthritis, the Reiter syndrome, ankylosing spondylitis, and enteropathic arthritis. Common characteristics are extraarticular ma-

nifestations and specific serological associations. Imaging procedures can be performed on all compartments of the musculoskeletal system and soft tissues to document the extent and distribution pattern of disease. They are, therefore, fundamental not only for differential diagnosis but also for conservative or surgical therapy decisions and follow-up.

arthropathies entities into classical spondylitis ankylosans and other diseases are possible.

Definition The common term “seronegative spondylarthropathies,” in contrast to rheumatoid arthritis, represents the main group of inflammatory joint diseases with a negative rheumatic factor. The main symptoms are inflammation of the axial skeleton in the form of spondylitis and sacroiliitis, as well as peripheral arthritis, but also enthesiopathies and other extra-articular manifestations. Table 37.1 summarizes the common features and the diagnostic criteria. There is a genetic predisposition and association with the histocompatibility antigen (HLA) B27 (Table 37.2). Transitions from the individual spondyl-

Diagnostic Imaging Radiography Regardless of the rheumatoid serology, the joint inflammations can be characterized radiographically by three main phenomena, which unspecifically represent the inflammatory pathomorphological processes of the joint:

Table 37.1 Dihlmann’s concept of seronegative spondylarthropathies U

U U

U U

U U U

Seronegative: IgM rheumatoid factor is not found more often than in the normal population No subcutaneous rheumatic nodules Inflammatory lesions of the axial skeleton and peripheral joints with differing incidence: – Sacroiliitis of the mixed type is characteristic, but not obligatory – Ankylosing spondylitis, Reiter’s or psoriatic spondylarthropathies can also occur – Asymmetric oligoarthritis (2–4 joints) or polyarthritis (> 4 joints) Enthesiopathies are common: fibro-ostitis Extra-articular manifestations are also present: – Skin: psoriasis-like rashes and nail diseases erythema nodosum pyoderma gangraenosum ulcers on the external genitals – Eyes: conjunctivitis anterior uveitis – Mucous membranes: maculae, erosions, and ulcers of the oral mucosa inflammations of the small and large intestines – Urogenital tract: urethritis, prostatitis – Blood vessels: thrombophlebitis At least two of the extra-articular characteristics must be present, either together or overlapping Familial frequency of one or several entities HLA B-27 and other HLA associations

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Soft-tissue signs of arthritis correspond to the swelling of articular and periarticular tissues, such as the synovium, the joint capsule, and their surroundings. Widening of the joint space caused by effusion or synovitic swelling can be seen in children and also in the hand and finger joints of adults. Collateral signs of arthritis represent periarticular demineralization of the subchondral and metaphyseal bone. They can be triggered by inflammatory circulatory disturbances, altered osteoblastic function, immobilization, and prostaglandins. Direct signs of arthritis are direct or indirect results of the destructive effect of inflammatory exudation and proliferation of the synovial membrane on bones and cartilage (Table 37.3).

U

U

U

Table 37.3 Dihlmann’s direct signs of arthritis U U

U U U

Concentric narrowing of the joint space Involvement and, finally, disappearance of the subchondral bone plate Marginal erosions on the bare areas of the joint Subchondral osteolytic cysts (geodes) Destruction of joint surfaces with mutilation, articular malalignment, and ankylosis

Table 37.2 HLA associations and coincidences (Dihlmann, Freyschmidt, and Zeidler) Ankylosing spondylitis

B27 (90–95 %), Bw62, (Bw35CREG), B7-CREG, Bw16

Psoriatic arthritis

B27 (+ sacroiliitis in about 70 %, sacroiliitis in about 35 %), B13, B17, Bw16(38), B37, Cw6, DRw7(4)

Reiter syndrome

B27 (in about 80 %)

Reactive arthritis

B27 up to 70 % (after Yersinia, Salmonella, or Shigella infections = “abortive” Reiter syndrome)

Enteropathic arthropathies U

Crohn disease

B27 (+sacroiliitis in about 70 %), Bw62

U

Ulcerative colitis

B27

U

Whipple disease

B27 coincidence

Behçet syndrome

B27, B5

Familial Mediterranean fever

B27 coincidence

Juvenile chronic polyarthritis

B27, B15, Bw3

Table 37.4 Rheumatoid arthritis vs. seronegative spondylarthropathies (Resnick)

Synovial joint involvement:

Rheumatoid Arthritis

Seronegative Arthritis

Generally proliferative

Generally inflammatory

U

Soft-tissue swelling

++

++

U

Marginal erosions

++

++

U

Central erosions and cysts

++

++

U

Osteopenia

++

(+)

U

Malalignment/subluxation

++

(+)

U

Bony ankylosis

+ (generally fibrous)

++

U

Bony proliferation

−

+++

++

++

Tendon and bursa involvement: U

Soft-tissue swelling

++

++

U

Bony erosions

++

++

U

Bony proliferation

−

++

+

++

Articular cartilage involvement: U

Bony erosions

+

++

U

Bony proliferation

+

++

U

Bony ankylosis

+

++

Enthesiopathies:

+

++

U

Bony erosions

+

++

U

Bony proliferation

+

++

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Seronegative Spondylarthropathies

a

b

c

d

Fig. 37.1 Distribution pattern of psoriatic arthritis of the hand. a Transverse type. b Axial type. c Mixed type. d Skeletal scintigram in psoriatic arthritis. Axial distribution on the left middle finger and mixed distribution pattern on the right hand

Table 37.4 differentiates seronegative spondylarthritis from rheumatoid arthritis. Four characteristics are useful in the differential diagnosis of seronegative polyarthritis: U Asymmetric distribution pattern U Lack of periarticular osteopenia U Bone proliferation U Bony ankylosis

Ultrasonography

Nuclear Medicine

In addition to differentiating pathologic soft-tissue swellings, CT imaging can also detect early erosions on the subchondral bone plate. A high-resolution reconstruction algorithm must be used. CT is superior to MRI in visualizing the bone structure. It is recommended to perform axial slices in the carpal area and longitudinal slices in the fingers. Puncture can be accurately guided with CT and ultrasonography (US).

Various techniques are available: U Three-phase skeletal scintigraphy with 99mTc phosphonates detects inflammatory soft-tissue reactions and osseous lesions at a very early stage. When several foci are located, the disease pattern can be defined ( F i g . 37.1 d). Follow-up examinations during therapy are controversial because they often do not provide any additional information to the clinical findings. U Joint scintigraphy with Tc-pertechnetate is rarely indicated. This radiopharmacologic agent accumulates only in the inflamed synovium and synovial fluid. Arthritic manifestation in the hand and fingers can be seen without overlapping, particularly in children. U Inflammation scintigraphy with 99mTc-HMPAO-labeled autologous leukocytes and Tc-nanocolloid, as well as immunoscintigraphy with 99mTc-labeled murine monoclonal granulocytes or human unspecific immunoglobulin, sensitively identify granulocyte-induced inflammations. Aseptic or chronic arthritides are generally not marked.

Differentiation between periarticular soft-tissue edema and effusions in joints and tendon sheaths (Chapter 7) can be achieved with a high-frequency probe (7.5 MHz and higher) using a water coupling.

Computed Tomography

Magnetic Resonance Imaging MRI is the method of choice to detect the early stages of intra- and extraarticular inflammation and the initial involvement of the bone marrow because of its superior differentiation of soft tissues. It provides a detailed view of the small joints, including cartilage, synovium (pannus), joint capsules, tendons, and bone marrow. Fat-suppressed T2-weighted sequences sensitively record edema in the bone marrow and soft tissues, as well as minimal effusions. Gadolinium dye should always be administered intravenously in patients with arthritic diseases because hyperemic lesions can be clearly detected and localized by their massive enhancement. Coronal slices in T1- and T2-weighted sequences are the procedures for standard orientation.

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Disease Entities

Psoriatic Arthritis (Psoriatic Osteoarthropathy) Pathoanatomy and Clinical Symptoms In 0.5–25 % of cases patients suffering from psoriasis, an independent polyarthritic syndrome develops with primarily erosive joint destruction on the hands and feet, as well as bone proliferation on the limbs and axial skeleton. Histology reveals nonnecrotizing synovitis and inflammatory reactions on the insertions of ligaments and tendons, as well as synchondroses. The coincidence of cutaneous psoriasis and rheumatoid arthritis is possible, when the cutaneous symptoms generally precede the joint complaints. In about 6 % of cases, the osteoarthropathy precedes the cutaneous symptoms. They rarely begin simultaneously, and psoriatic arthritis without psoriasis is also rare.

Diagnostic Imaging

ized by asymmetric parasyndesmophytes–paradiscal, lumpy new bone formations to be differentiated from the syndesmophytes of ankylosing spondylitis. Involvement of the medium-sized and large joints is rarer and radiomorphologically comparable to rheumatoid arthritis.

Magnetic Resonance Imaging Fat-suppressed T1-weighted SE sequences with gadolinium play a decisive role in diagnosis (Fig. 37.5). Inflamed capsular insertions, which correspond to erosive defects in radiography, and concomitant findings, such as hyperemia of the joint capsule, the synovium, and the periarticular periosteum, can be directly visualized. Periarticular bone marrow edema and small joint effusions appear hyperintense in T2-weighted sequences with fatsuppression.

Radiography

Differential Diagnosis

The characteristic pattern of distribution on the hand (Table 37.1) and the combination of osteoproliferative and osteodestructive lesions (Table 37.5, Figs. 37.2–37.4 and 37.5) are useful for differential diagnosis. Involvement of bone sections and soft tissues far from joints leads to the typical appearance of psoriatic dactylitis. On the foot, psoriatic arthritis is manifested by erosive defects on the interphalangeal and metatarsophalangeal joints, as well as fibro-ostitis on the calcaneus in the insertion of the Achilles tendon and the plantar aponeurosis. A fairly asymmetric sacroiliitis is found in 30–50 % of cases. Psoriatic spondylitis is character-

In addition to Reiter syndrome, which primarily affects the lower extremities, ankylosing spondylitis and rheumatoid arthritis must be differentiated from erosive osteoarthritis, the various forms of hyperparathyroidism, and, with oligoarthritic and monarthritic onset, gouty arthritis and panaritium.

Therapeutic Options The course of the disease (spontaneous, oligoarticular, or mutilating) and articular involvement (peripheral or axial, functionally relevant or irrelevant) are decisive for

Fig.37.2 a–c Typical radiographic signs in psoriatic arthritis of the hand. See Fig.37.4 for mutilating psoriatic arthritis. a “Mouse-ear” protuberances and frayed erosions. b Intra-articular ankyloses. c Undulating periosteal reaction of the proximal phalanges and tuftal distal interphalangeal joint configurations.

a

b

c

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Psoriatic Arthritis (Psoriatic Osteoarthropathy)

Ü

Ü

Ü

Ü

U

Fig. 37.3 Transverse form of psoriatic arthritis (DIP prevalence). Marginal erosions (arrowheads) and fine osseous proliferations on distal interphalangeal joints II–V. Undulating periosteal osteosclerosis on proximal phalanx III (arrow).

a

b

Fig. 37.4 Mutilating form of psoriatic arthritis. Intra-articular ankyloses of the carpus. “Pencil-in-cup” deformities of the metacarpophalangeal and interphalangeal joints with dislocations. No periarticular osteopenia. Irregular contours (“frayed” appearance) of the carpal and metacarpal bones on the radial side caused by a combination of erosion and proliferation.

c

d

Fig. 37.5 a–d Axial form of psoriatic arthritis (MP, PIP, DIP concordance) in long-standing psoriatic disease. (Courtesy of R. Schmitt, MD, Bad Neustadt/Saale.) soft-tissue swelling, edema, and hyperemic bone marrow a The radiograph shows periarticular osteopenia and marginal corresponding to the periarticular osteopenia, as well as erosions, especially in the proximal interphalangeal joint. Dissynovitis in the metacarpophalangeal, proximal and distal tinct soft-tissue swelling. interphalangeal joints and small joint effusions. The b Corresponding MRI with a fat-saturated PD-weighted FSE inflamed, hyperemic capsular insertions, which correlate sequence. with the marginal erosions on the proximal interphalangeal c, d T1-weighted SE sequences plain (c) and fat-saturated (d) joint, can be clearly seen. following application of gadolinium. There is periarticular

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therapy. Treatment of joints consists of a combination of physical and pharmacologic anti-inflammatory therapy ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to cytostatics and immunosuppressants. Early synovectomy prevents joint mutilation and is appropriate for oligoarticular forms. Arthrodesis is performed to stabilize destroyed finger joints. The indication for joint replacement is the same as in rheumatoid arthritis.

Reiter Syndrome (Reiter disease)

Table 37.5 Radiographic signs of psoriatic arthritis and psoriatic dactylitis Pattern of involvement: U

U

U

Transverse type: involvement of the distal interphalangeal joints and the interphalangeal joint of the thumb (prevalence) Axial type: metacarpophalangeal and proximal interphalangeal and distal joints of one or several fingers (MP, PIP, DIP concordance) Mixed type: combination of transverse and axial types

Articular lesions: U

Pathoanatomy and Clinical Symptoms

U

Reiter disease is androtropic and appears as a classic triad with urethritis (85 %), conjunctivitis (60 %), and arthritis (100 %) (urethro-oculo-synovial syndrome), sometimes with diarrhea. Mucocutaneous lesions, such as palmoplantar keratoderma, balanitis, keratosis blennorrhagica, lesions in the oral mucosa, and onychopathy, can also appear. Incomplete Reiter syndrome describes arthritis combined only with urogenital or ocular inflammation. Reiter syndrome occurring after venereal or gastrointestinal infections is referred to as reactive arthritis by most authors.

U

U

U

U

Radiography The joints of the lower extremities are predominantly and asymmetrically affected. In principle, any joint can be affected, as are primarily the joints of the hand (Table 37.6, Fig. 37.6). Occasionally, Reiter syndrome displays the pathognomonic radiographic course of a painful arthritis of the fingers or toes. This dactylitis begins acutely with a formidable soft-tissue swelling and, after four days at the earliest, shows a fine metadiaphyseal periosteal lamella. After five to ten days, periarticular decalcification occurs. Sacroiliitis, which is often unilateral and has only mild symptoms, is almost always present. Spondylarthropathy is characterized by parasyndesmophytes, but ankylosing spondylitis and fibro-ostoses on the coccyx and calcaneus can also be found.

U

Periarticular osteopenia in the acute stage Narrowing of joint space as a result of breakdown of cartilage and bones Pseudo-narrowing of joint space due to resorptive processes of the subchondral bone plate Erosions: – Begin at the margins – Subchondral expansion leads to “pencil in cup” joint and cup-, mushroom- or club-shaped phalanx – Frayed look caused by a multiple, small bony proliferations at the margins (whiskering) Osteoproliferation: – Periarticular, combined with osteosclerosis of the capsules and ligaments – Leads to typical “mouse-ear” protuberances Mutilations and intra-articular ankyloses: – Develop relatively early – Irregular subluxations and dislocations Opera-glass deformity in the final stage

Psoriatic dactylitis: U

U

U

U

Sausage-shaped fingers caused by swelling of all the soft tissues “Morning-star” appearance caused by destruction of the ungual tuberosity (acro-osteolysis) Productive fibro-ostitis: irregular ossifications on the attachments of the flexor tendons Periosteal sclerosis of the metaphyses and diaphyses: – Lamellar or undulating – Leads to a cup-, mushroom-, or club-shaped phalanx – “Ivory” phalanx is rare

Differential Diagnosis Differential diagnoses include psoriatic arthritis primarily affecting the hands, ankylosing spondylitis, enteropathic arthritis, and rheumatoid arthritis.

Therapeutic Options Therapy is the same as for reactive arthritis.

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Reactive Arthritis

Reactive Arthritis

Table 37.6 Radiographic signs in Reiter syndrome U

Pathoanatomy and Clinical Symptoms U

Soft-tissue swelling of the entire finger as in psoriatic arthritis is possible Periarticular osteopenia only in the acute phase Periosteal reactions: – Lamellar in the acute stage – Irregular when chronic Narrowing of the joint space Marginal erosions: common on the hand, without joint destruction Mutilation and ankylosis: – In up to 50 % of chronic cases – In combination with discrete osseous proliferation

Reactive arthritis is assumed to be an aseptic synovitis that is triggered by immunologic processes 1–4 weeks after an infection. The prototype was previously rheumatic fever (Chapter 38) after an infection of the upper respiratory tract with β-hemolytic streptococci. The classic example today is Reiter disease (Section 37.4). In postenteritic and postvenereal reactive arthritis, antititers against the following causative agents can be serologically identified: Chlamydia trachomatis, Yersinia enterocolitica (more often than Yersinia pseudotuberculosis), Shigella, Salmonella, Campylobacter jejuni, Klebsiella, Brucella, Neisseria gonorrhoeae, Ureaplasma urealyticum, and Clostridium difficile. There is an association with HLA-B27 in up to 80 % of cases, which makes differentiation of these reactive arthritic diseases from Reiter syndrome of little use, as the terms can be applied synonymously. Since single bacteria have recently been located in the synovial cells or in a joint, a discrete infective arthritis is under discussion as a pathogenesis (see Chapter 40).

posed sites and are affected by acute inflammation. Softtissue swelling and enthesiopathies are sometimes accompanied by fever, iritis, and myocarditis. Psoriatic forms of cutaneous lesions are also observed. The small joints of the hand can be affected when there is migratory arthritis (Fig. 37.7). Unilateral sacroiliitis is also often seen. When there is recurrent or chronic disease, reactive arthritis can progress to ankylosing spondylitis.

Radiography

Differential Diagnosis

Reactive arthritis usually is manifested asymmetrically on the lower extremities. Its radiographic appearance is unspecific, making the typical clinical course the decisive diagnostic criterion. The knees and ankles are predis-

Psoriatic arthritis occurring predominantly on the hand, peripheral arthritis of ankylosing spondylitis, and rheumatoid arthritides are to be considered in differential diagnosis.

U

U U

U

n n

Fig. 37.6 Reiter syndrome with initial radiographic symptoms. On the ulnar sides of the bases of metacarpals I and V there are marginal erosive lesions (arrowheads) and flat periosteal appositions on metacarpal V. No joint destruction.

Fig. 37.7 Reactive arthritis of presumed gastrointestinal origin. Mild arthritic signs in a radiograph on the radiocarpal and carpal joints. Decalcification near the fifth carpometacarpal joint. Flat erosions on the ulnar styloid process.

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Therapeutic Options Fundamentals of treatment are prophylaxis of infection and early antibiotic treatment of urethritic and enteritic infections. Acute arthritis and enthesopathy can be well controlled with NSAIDs. Intra-articular or systematic

application of glucocorticoids may occasionally be necessary. When the course is chronic despite treatment with sulfasalazine, methotrexate and azathioprine are administered.

Arthritis with Ankylosing Spondylitis (Marie–Strümpell Disease, Bechterew Syndrome) Pathoanatomy and Clinical Symptoms

Differential Diagnosis

Peripheral arthritis is observed in more than 50 % of cases of Marie–Strümpell disease. Involvement of the central joints of the or near the trunk is differentiated from arthritis of the lower extremities and asymmetric, erosive oligoarthritis or polyarthritis without a specific pattern of distribution. In the upper extremities, the wrist is most often affected (in up to 30 % of severe ankylosing spondylitis).

Differential diagnoses include other HLA-associated spondylopathies and rheumatoid arthritis.

Radiography All carpal compartments, the metacarpophalangeal, proximal, and distal interphalangeal joints, and the ulnar styloid process can be affected (Table 37.7, Fig. 37.8).

Therapeutic Options NSAIDs are generally not sufficient in acute inflammatory episodes on the axial skeleton and peripheral joints. Occasionally, intra-articular injections or systemic administration of corticosteroids becomes necessary. Sulfasalazine or methotrexate can be administered in chronic cases. Physiotherapy is effective only before stiff syndesmophytes have formed.

Table 37.7 Radiographic signs in ankylosing spondylitis U U U

U

U

Periarticular soft-tissue swelling Subchondral and metaphyseal osteopenia Narrowing of joint space: occasionally rapid intra-articular osseous ankylosis Erosions: lead to periosteal reactions and osseous proliferation causing contour irregularities Articular malalignment is extremely rare: – Ulnar translocation of the carpus – Ulnar deviation in the metacarpophalangeal joints

Table 37.8 Arthritis associated with gastrointestinal diseases U U U U U U

Fig. 37.8 Peripheral arthritis in ankylosing spondylitis. Periarticular osteopenia around the carpal and metacarpophalangeal joints. Erosive arthritis in the distal radioulnar joint, the radiocarpal joint, and the entire carpus. The ulnar styloid process is also involved. Destructive arthritis with coarse erosions, osteoproliferation, and subluxations in metacarpophalangeal joints I and III.

U U U U U U

Regional enteritis, Crohn disease Ulcerative colitis Intestinal lipodystrophy, Whipple disease Intestinal bypass arthropathy Primary biliary liver cirrhosis Chronic hepatitis Inflammatory and neoplastic pancreatic diseases Carcinoid syndrome Celiac disease Cystic fibrosis Juvenile gastrointestinal polyposis Cronkhite–Canada syndrome

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Enteropathic Arthritis

Enteropathic Arthritis Table 37.9 Radiographic signs of enteropathic arthritides

Pathoanatomy and Clinical Symptoms Either seronegative, HLA-associated arthritic diseases or reactive arthritis can occur with many gastrointestinal diseases. The basic pathophysiology with the underlying diseases remain largely unclear (Table 37.8). Infectious, immunological, and genetic factors (HLA B27) have been discussed. Sacroiliitis and ankylosing spondylitis are known to occur with ulcerative colitis (up to 30 %), Crohn disease (up to 16 %), Whipple disease, and bypass arthropathy. Peripheral arthralgias and arthritis are found in up to 90 % of Whipple disease, up to 60 % of ulcerative colitis, up to 25 % of Crohn disease and bypass arthropathies, and, less often, with viral hepatitis, primary biliary liver cirrhosis, pancreatic diseases, the carcinoid syndrome, and celiac disease. Cystic fibrosis, juvenile gastrointestinal polyposis, and the Cronkhite– Canada syndrome can also be associated with arthritic diseases.

Regional enteritis (Crohn disease): U

U

U

Ulcerative colitis: U U

Digital clubbing in about 5 % of cases Hypertrophic osteoarthropathies with periosteal and subperiosteal appositions

Intestinal lipodystrophy (Whipple disease): U

Radiography Most transitory oligoarthropathies and polyarthropathies in case of enteropathic arthritis occur predominantly on the lower extremities. The radiographic findings are minimal and unspecific at best. Individual enteropathies can, however, be accompanied by characteristic, but rare and nonpathognomonic, lesions on the hand (Fig. 37.9). Table 37.9 lists the most important radiographic signs.

Convexity of the nails (“hour-glass nails”) and digital clubbing in more than 10 % of cases Arthritic collateral and direct signs: – Proximal pattern of distribution on the carpus and PIP joints – Periarticular osteopenia – Narrowing of joint spaces, erosions Hypertrophic osteoarthropathy with lamellar periosteal reaction

U

Arthritic collateral and direct signs: – On the carpal and metacarpophalangeal joints – Osteopenia – Narrowing of joint spaces, erosions – Severe destruction of joints possible Osteophytes

Primary biliary liver cirrhosis: U U

U

U U

Digital clubbing Erosive arthritis: – Asymmetric, especially on the proximal and distal interphalangeal joints – Metacarpophalangeal joints usually not involved – Marginal erosions of different sizes (cholesterol deposits, xanthomas, synovitis) – Narrowing of joint spaces possible, no deformities Osteopenia and subperiosteal resorption on the radial side of the middle phalanges as in hyperparathyroidism Acro-osteolyses Periarticular calcifications

Pancreatic diseases: U

U U

“Motheaten” destruction of the small tubular bones and periostitis due to acute fatty necroses Cystoid, stringy cancellous bone in the chronic stage Bizarre osteosclerosis of the cancellous bone caused by infarcts

Carcinoid syndrome: U U

U U

Fig. 37.9 Enteropathic arthritis in a patient with Whipple disease. Erosive destructions, especially at the proximal carpal row. Osteoproliferation at the ulnar styloid process. So-called arthritic collateral signs, which are commonly seen in rheumatoid arthritis, are not present. (Courtesy of W. Zilly, MD, Bad Brückenau.)

Periarticular osteopenia Extensive subchondral and diaphyseal osseous resorption on the phalanges Multiple cystic lesions on the phalanges, erosions Acro-osteolyses

Celiac disease: U U

U

Digital clubbing and hour-glass nails Sclerodactyly with flexion contractures of the fingers without erosions Regression with gluten-free diet

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Differential Diagnosis

Therapeutic Options

The heterogeneous group of enteropathic arthritic diseases can best be differentiated from psoriatic arthritis, Reiter syndrome and other reactive arthritides, ankylosing spondylitis, rheumatoid arthritis, and hyperparathyroidism by clinical findings.

Aside from treating the underlying disease, NSAIDs have only limited use (diarrhea). Intra-articular injections of corticosteroids are indicated for monarthritis.

Osteoarthropathies Associated with Dermatoses There is ongoing discussion about a broad group of disease entities affecting the skin, mucous membranes, bones, and joints. These entities are still referred to by different synonyms with no clear nosological definition. These include pustular arthro-osteitis, spondylarthritis hyperostotica pustulopsoriatica, the SAPHO syndrome (synovitis, acne, pustular hyperostosis, osteomyelitis), and the acquired hyperostosis syndrome.

on the diaphyses of the metacarpus and fingers. Common manifestations are sternocostoclavicular hyperostosis, enthesiopathies of the vertebral and sacroiliac joints, and osteoproliferation, e.g., on the distal femur, that resembles a bone tumor.

Therapeutic Options NSAIDs are administered to control symptoms. Corticosteroids are often ineffective. Attempts have been made with radiotherapy and surgery (partial resection).

Radiography Asymmetric arthralgias often have no direct radiographic signs of arthritis. Lamellar periosteal hyperostoses can be found

Rare Seronegative Arthritides Arthritides occurring together with the following disease entities are considered absolute rarities.

Antibody-deficiency Syndrome Agammaglobulinemia or hypogammaglobulinemia is associated with chronic polyarthritis in 30 % of cases. The clinical and radiographic findings partially resemble those of rheumatoid arthritis. Asymmetric distribution, osteoporosis, and joint deformities without erosions, like Jaccoud arthropathy, are characteristic.

Hashimoto Autoimmune Thyroiditis The association between Hashimoto thyroiditis and chronic polyarthritis is definite. The radiographic aspect is that of rheumatoid arthritis. Hashimoto thyroiditis often occurs together with collagenoses, especially lupus erythematosus and Sjögren syndrome.

Behçet Disease If this oculomucocutaneous syndrome causes joint symptoms, one speaks of Behçet’s tetralogy. Although direct arthritic signs are uncommon, erosive-destructive lesions can sometimes be found on the interphalangeal joints. Unilateral sacroiliitis or spondylitis can also occur, but these are possibly associated with Crohn disease or ulcerative colitis (Section 37.5).

Familial Mediterranean Fever This autosomal recessive, recurrent polyserositis is accompanied by intermittent musculoskeletal symptoms in 60–70 % of cases. There are no typical radiographic findings in the hand. The large joints of the lower extremities are predisposed sites, and manifestations are asymmetrical. Fibrous ankyloses have been observed, and sacroiliitis is common.

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Rare Seronegative Arthritides

Stevens–Johnson Syndrome Erythema multiforme exudativum, like Reiter disease and Behçet disease, is a mucocutaneous syndrome and is characterized by a highly aggressive course. No specific radiographic finding is known, and acute bacterial arthritis must be excluded.

Further Reading Atkin SL, El-Ghobarey A, Kamel M, Owen JP, Dick WC. Clinical and laboratory studies of arthritis in leprosy. Br Med J. 1989;124: 1423–1425. Amor B. Reiter’s syndrome and reactive arthritis. Clin Rheum. 1983;2: 315–319. Barakat MS, Schweitzer ME, Morisson WB, Culp RW, BordaloRodrigues M. Reactive carpal synovitis: Initial experience with MR imaging. Radiology. 2005;236:231–236. Bassiouni M, Kamel M. Bilharzial arthropathy. Ann Rheum Dis. 1984; 43:806–809. Bocanegra TS, Epinoza LR, Bridgeford PH, Vasey FB, Germain BF. Reactive arthritis induced by parasitic infestation. Ann Intern Med. 1981;94:207–209. Boutry N, Hachulla E, Flipo RM, Cortet B, Cotten A. MR imaging findings in hands in early rheumatoid arthritis: Comparison with those in systemic lupus erythematosus and primary Sjogren syndrome. Radiology. 2005;236:593–600. Broich P, Jerusalem F. Polymyositis, Dermatomyositis und andere entzündliche Muskelerkrankungen. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:964–995. Delamere JP, Baddeley RM, Walton W. Jejuno-ileal bypass arthropathy: Its clinical features and associations. Ann Rheum Dis. 1983; 42:553–557. Fischer E. Enthesopathic reactions of the wrist in psoriatic arthritis, chronic polyarthritis and diffuse idiopathic skeletal hyperostosis. Results based on 3-dimensional soft radiographs. Radiologe. 1989; 29:73–81. Fogelman I, Maisey MN, Clarke SEM. An Atlas of Clinical Nuclear Medicine. 2nd ed. London: Martin Dunitz; 1994. Fujita A, Sugimoto H, Kikkawa I, Hyodoh K, Furuse M, Hoshino Y. Phalangeal microgeode syndrome: Findings on MR imaging. Am J Roentgenol. 1999;173:711–712. Giovaganoni A, Grassi W, Terilli F et al. MRI of the hand in psoriatic and rheumatical arthritis. Eur Radiol. 1995;5:590–595. Hameed K, Karim M, Islam N, Gibson T. The diagnosis of Poncet’s disease. Br J Rheum. 1993;32:824–826. Hein G. Differentialdiagnose von Arthritis psoriatica (Osteoarthropathia psoriatica) und chronischer Polyarthritis (Rheumatoidarthritis). Z Ärztl Fortbild. 1992;86:967–971. Krüger K. Enteropathische Arthropathien. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:700–710. Krüger K.. Reaktive Arthritiden. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:720–734. Loreck D, Schulz P, Miehe M. Röntgenmorphologische Befunde am Skelettsystem bei der Psoriasis arthropathica 1. Mitteilung: Handund Fußskelett, andere Gelenke. Radiol Diagn. 1981;22:651–662.

Luzar MJ, Caldwell JH, Mekhjian H, Thomas FB. Yersinia enterocolitica infection presenting as chronic enteropathic arthritis. Arthrit Rheum. 1983;26:1163–1165. Manaster BJ. Handbook of Skeletal Radiology. 2nd ed. St. Louis: Mosby; 1997:104–170. Martel W, Stuck KJ, Dworin AM, Hylland RG. Erosive osteoarthritis and psoriatic arthritis: A radiologic comparison in the hand, wrist, and foot. Am J Roentgenol. 1980;134:125–35. Miehle W. Arthritis psoriatica. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:680–699. Miehle W. Spondylitis ankylosans. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:629–679. Murphy WA, Staple TW. Jaccoud’s arthropathy reviewed. Am J Roentgenol. 1973;118:300–307. Norton KI, Eichenfield AH, Rosh JR, Stern MT, Hermann G. Atypical arthropathy associated with Crohn’s disease. Am J Gastroent. 1993; 88:948–952. Olivieri I, Barozzi L, Favaro L. Dactylitis in patients with seronegative spondyloarthropathy: Assessment by ultrasonography and magnetic resonance imaging. Arthritis Rheum. 1996;39:1524–1528. Pile KD. Reactive arthritis, infection and antigens. N Zeal Med J. 1990; 53:556–557. Resnick D. Patterns of peripheral joint disease in ankylosing spondylitis. Radiology. 1974;110:523–530. Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: Saunders; 2002. Saag KG, Niemann TH, Warner CA, Naides SJ. Subcutaneous pancreatic fat necrosis associated with acute arthritis. J Rheum. 1992;19: 630–632. Schattenkirchner M, Krüger K, Herzer P. B27-positive diseases. A new concept in rheumatology. Münch med Wschr. 1980;122: 1725–1728. Schilling F, Stadelmann ML. Klinik und Röntgenmorphologie der Arthritis psoriatica. Coll Rheum. 1984;18:29–47. Schlumpf U, Vogt M. Gelenkinfektionen und Arthritiden bei Infektionskrankheiten. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:753–776. Schneider P. Viral arthritides in man. Münch med Wschr. 1981;123: 1891–1894. Schröder JO, Harten P, Euler HH. Systemischer Lupus erythematodes. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000: 909–953. Sieper J, Braun J, Laitko S et al. Reactive arthritis associated bacteria as the etiology of undifferentiated oligoarthritis. Z Rheum. 1993;52: 19–27. Sollberg S, Krieg T. Systemische Sklerose. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:954–963. Uhl M. Radiology of the manual skeleton. 1. Inflammatory joint diseases and rheumatology. Radiologe. 1999;39:432–449. Uhl M. Radiology of the skeleton of the hand. 2. Degenerative joint diseases. Endocrine and metabolic bone diseases. Radiologe. 1999; 39:1083–1100. Yurdakul S, Yacici H, Tüzün Y et al. The arthritis of Behcet’s disease: A prospective study. Ann Rheum Dis. 1983;42:505–515. Zammit Maempel I, Adamson AR, Halsey JP. Sklerodactyly complicating coeliac disease. Br J Rheum. 1986;25:396–398.

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Rheumatic Fever (Poststreptococcal Reactive Arthritis) S. Spindler-Thiele, G. Lingg

Pathoanatomy and Clinical Symptoms Rheumatic fever is rarely seen today. The infection with β-hemolytic streptococci, group A, leads to a systemic inflammatory reaction via a secondary immunopathogenesis. In 20–70 % of cases, there is a carditis and endocarditis, and in 50–80 %, there is a recurrent polyarthritis

corresponding to classic reactive arthritis. Sydenham chorea seldom appears, and Jaccoud arthropathy, which is now rare, develops as a result of multiple episodes of polyarthritis.

Radiography Two forms of disease progression have been described: U Acute articular rheumatism becomes manifest in several joints either simultaneously or in quick succession as migrating polyarthritis and usually affects the ankles and knees. Aside from soft-tissue swelling, only discrete periarticular osteopenia can be seen in radiographs.

a

b

c

Jaccoud arthritis, a nonerosive arthropathy that is referred to as chronic rheumatic fever and chronic postrheumatic polyarthritis, leads to characteristic signs in the hands (Table 38.1, Figs. 38.1 a, 38.2).

U

Table 38.1 Radiographic signs of Jaccoud arthritis U

U U

U

Fig.38.1 a, b Schematic drawing of different forms of erosions and joint destruction. a Hooklike erosions are extra-articular, usually metaphyseal. They are observed in Jaccoud arthritis, rheumatic fever, and lupus erythematosus. b Marginal erosions are seen in rheumatoid arthritis. c Epiphyseal osteonecroses are characteristic of lupus erythematosus.

U

Painless and elastic malalignments: – Ulnar deviation and flexion in the metacarpophalangeal joints, especially of fingers IV and V – Hyperextension in the interphalangeal joints Discrete periarticular osteopenia Narrowing of the joint space is rare (usually as a result of subluxation) Hooklike erosions: – Develop rarely and only in late stages – On the metaphyses and radiopalmar on the metacarpal heads No lesion in the carpal and interphalangeal joints

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Therapeutic Options

Differential Diagnosis Acute manifestations include septic arthritis, reactive arthritis in general, Still disease, and Lyme arthritis. Jaccoud arthropathy in rheumatic fever is comparable to the manifestations of systematic lupus erythematosus on the hand, but is not most prominent at the ulnar side and affects all fingers. Jaccoud arthropathy can be differentiated from rheumatoid arthritis by its early marginal erosions and cartilaginous destruction. The possibility of sarcoidosis, agammaglobulinemia, and the Ehlers–Danlos syndrome must also be considered.

Therapeutic Options First and foremost the streptococci must be eradicated. The polyarthritis is treated with salicylates or with other nonsteroidal anti-inflammatory drugs (NSAIDs) for 6–8 weeks. Long-term prophylaxis with penicillin G parenteral, penicillin V oral, or erythromycin if there is a penicillin allergy should be administered according to the current WHO guidelines.

Further Reading See references listed in Chapter 37. Aigner RM, Fueger GF. Nuklearmedizinische Diagnostik. In: Brussatis F, Hahn K, eds. Nuklearmedizin in der Orthopädie. Heidelberg: Springer; 1990. Dreher R. Über den Stellenwert der Gelenkszintigraphie in der Arthritisdiagnostik. In: Brussatis F, Hahn K, eds. Nuklearmedizin in der Orthopädie. Heidelberg: Springer; 1990. Frey D, Tyndall A. Rheumatisches Fieber. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:735–741. Murphy WA, Staple TW. Jaccoud’s arthropathy reviewed. Am J Roentgenol. 1973;118:300–307. Pile KD. Reactive arthritis, infection and antigens. N Zeal Med J. 1990; 53:556–557. Sieper J, Braun J, Laitko S et al. Reactive arthritis associated bacteria as the etiology of undifferentiated oligoarthritis. Z Rheum. 1993;52: 19–27.

Fig. 38.2 Jaccoud arthritis. In the dorsopalmar radiograph of a patient with chronic postrheumatic polyarthritis (Jaccoud arthritis), there are hyperextensions in interphalangeal joints IV and V and discrete periarticular osteopenia, but no erosions.

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Collagenoses S. Spindler-Thiele, R. Schmitt

Clinically heterogeneous systemic diseases are included in the term collagenoses, which was coined by Klemperer in 1942. They have in common a generalized inflammatory reaction in the connective tissue with fibrinoid necroses and degeneration, as well as autoantibodies, which will not be further discussed

here. Vasculitic diseases can be included in the classic collagenoses due to their clinical and immunological similarities. The following disease entities all affect the joints, and therefore illustrate the overlapping of symptoms within the systemic connective-tissue diseases.

Systemic Lupus Erythematosus (SLE) Pathoanatomy and Clinical Symptoms

Therapeutic Options

Antinuclear antibodies, among other pathophysiologic processes, lead to immune-complex vasculitis, which has an episodic course and primarily affects women of childbearing age (female:male ratio = 10:1). A genetic predisposition is assumed because of the DR3 association in 60 % of cases. The disease can be triggered by ultraviolet light, viruses, and hormonal changes. Lupus erythematosus is manifested in the skin (butterfly erythema), the musculoskeletal system, internal organs (nephritis, myocarditis, serositis), and the nervous system. In 90 % of cases, there are arthralgias, which predominantly affect the joints of the hands and the knees with symmetric soft-tissue swelling.

Depending on the disease activity, one can either wait or treat with immunosuppressive drugs. These include nonsteroidal anti-inflammatory drugs (NSAIDs), lowdose corticosteroids, hydroxychloroquine, azathioprine and even cyclophosphamide. The effectiveness of methotrexate, cyclosporine A, intravenous immunoglobulins, androgens, plasmapheresis, and immunoadsorption has not been confirmed.

Table 39.1 Radiographic signs of lupus erythematosus U

Radiography Typical findings are severe articular malalignments in the hands due to ligamentary instability without any other radiographic lesions (Table 39.1, Figs. 38.1 c, 39.1, 39.2).

Differential Diagnosis

U

Differential diagnoses include rheumatoid arthritis, which can be differentiated by the typical marginal erosions (see Figs. 36.1 and 38.1 b), Jaccoud arthropathy of rheumatic fever, which predominantly affect the ulnar side, Sharp syndrome, Ehlers–Danlos syndrome with articular malalignment, subcutaneous fat necroses, and signs of deforming osteoarthritis, as well as avascular osteonecroses.

U

U

U U

Nonerosive, deforming arthropathies in about 10 % of cases: – Severe articular malalignment: Ulnar deviation of the metacarpophalangeal joints Subluxation of the trapeziometacarpal joint Elastic flexion and extension of the interphalangeal joints (swan-neck and button-hole deformities), may not appear in dorsopalmar radiographs because of positioning – Symmetric soft-tissue swelling – Periarticular osteopenia Subcutaneous soft-tissue calcifications in fewer than 10 % of cases Ischemic osteonecroses in up to 3 %: – Epiphyseal osteonecroses usually in the metacarpal heads – Osteonecroses of the lunate and triquetrum – Cystoid radiolucency, increased density, fragmentation, and deformation of bones Hooklike erosions are occasionally seen on the metaphyses Acro-osteolysis and acro-osteosclerosis are rare Raynaud phenomenon can be visualized in pharmacoangiography

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Systemic Lupus Erythematosus (SLE)

a

b

Fig. 39.1 a, b Arthropathic manifestation of systemic lupus erythematosus. Severe interphalangeal malalignment, which is well visualized in the semipronated oblique view. Swan-neck deformities with elastic hyperextension of the proximal interphalangeal joints and flexion in the distal interphalangeal joints. Subluxation of the trapeziometacarpal joint. No erosions. Periarticular osteopenia.

a

b

c

d

Fig. 39.2 a–d Long-standing lupus erythematosus with articular instability and unusual erosions. a The dorsopalmar radiograph shows advanced destruction of the radiocarpal joint with ulnar translocation of the carpus. Large osteolyses in the radial epiphyse, and erosions in the trapezoid. b Coronal multiplanar reconstruction of an axial CT data set shows the extent of destruction on the radiocarpal joint compartment. Multiple carpal erosions and osteolyses. c Coronal T1-weighted SE sequence with fat saturation displays extensive contrast enhancing synovitis. d Axial CT scan shows a dislocation of the radius toward the palmar side. Note the deep erosions and osteolyses.

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Scleroderma, Progressive Systemic Sclerosis (PSS) Pathoanatomy and Clinical Symptoms Overproduction of collagen and obliteration of small blood vessels leads to inflammatory, fibrotic, and regressive lesions in the cutis and subcutis, as well as in internal organs. Manifestations in the gastrointestinal tract, lungs, kidneys, heart, transverse-striated muscles, and

bones result in the classic disease entity of progressive scleroderma, as well as a number of variants, which are listed in Table 39.2. Painful micronecroses of the integument arise as a result of the underlying angiopathy. Immobile joints are a result of fibrosis of the synovium. Women in their third to fifth decades of life are primarily affected (female:male ratio = 3:1).

Table 39.2 Variants of scleroderma Progressive systemic scleroderma (PSS)

Classic systemic manifestation at the skin and early visceral involvement

Thibièrge–Weissenbach syndrome

PSS combined with soft-tissue calcifications

CREST syndrome

Relatively benign variant of PSS: C = calcinosis (Thibièrge–Weissenbach syndrome) R = Raynaud phenomenon E = esophageal dysfunction S = sclerodactyly T = telangiectasias

Sharp syndrome

Mixed connective-tissue disease (MCTD) is an overlapping syndrome of PSS with lupus erythematosus, polymyositis/dermatomyositis, and rheumatoid arthritis

Shulman syndrome

Eosinophilic fasciitis without involvement of internal organs, symmetric serous polyarthritis, rarely erosions, carpal tunnel syndrome

Focal scleroderma

Delineated sclerosis of the skin without involvement of internal organs

Secondary scleroderma

Caused by bleomycin, pentazocine, vinyl chloride, and solvents

A

B

a

b

c

d

e

f

Fig. 39.3 a–f Radiographic appearance of acral lesions in scleroderma. a YUNE soft-tissue index for early detection of acral soft-tissue atrophy. Normally, A ≥ B/4. If A ≤ B/5, the condition is pathologic. Normal soft-tissue covering with areactive osteolysis on the unguinal tuberosity and soft-tissue calcinosis at the level of the distal interphalangeal joint. b Acral soft-tissue atrophy with “sugar-loaf” configuration in advanced scleroderma.

c Early acro-osteolysis in the form of a so-called “rat-bite” defect (arrow). d Band-shaped acro-osteolysis. e Spotty acral soft-tissue sclerosis distal of the unguinal tuberosity. f Plaque-shaped calcinosis interstitialis localisata. Thibièrge–Weissenbach syndrome.

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Scleroderma, Progressive Systemic Sclerosis (PSS)

Fig. 39.4 Mutilation stage of scleroderma. Claw hand resulting from severe sclerodactyly. Destructive arthritis with areactive osteolyses in all phalanges and the ulnar styloid process. Nearly complete resorption of the third and fifth distal phalanges. Diffuse osteopenia. Interstitial calcinoses in the phalangeal soft tissues.

Fig. 39. 5 Sharp syndrome (mixed connective-tissue disease). The flexion contractures of the fingers and the subluxations of metacarpophalangeal joints IV and V resemble lupus erythematosus; in contrast, the plaquelike and streaky soft-tissue calcifications are typical of dermatomyositis/polymyositis. Destruction of the ulnar styloid process and periarticular osteopenia. (Courtesy of A. Stäbler, MD, Munich.)

Table 39.3 Radiographic signs of scleroderma of the hand U

U

U

U

U

Atrophy of soft tissues in 78 % of cases: – Sclerodactyly: atrophic skin of the fingers, which can lead to fixed claw hand, early diagnosis with the YUNE soft tissue index – Sugar-loaf finger form in advanced stages Resorption of bone in up to 80 % of cases: – Areactive osteolyses on the fingertips, manifested early as “rat-bite” defects on the palmar side of the unguinal tuberosity – Resorption on trapeziometacarpal joint with radial subluxation of metacarpal I – Osteolyses on the radial and ulnar styloid processes Soft-tissue calcifications in 25 % of cases: – Localized interstitial calcinosis: subcutaneous spotty sclerosis of the fingertips, also periarticular, rarely intra-articular – Universal interstitial calcinosis: diffuse calcifications, sometimes as large conglomerates Osteoporosis in 80 % of cases: – Osteopenia of the hand skeleton – diffuse or band-shaped around joints Destructive polyarthritis in about 25 % of cases: – Typically manifested on the proximal and distal interphalangeal joints without affecting the carpus or the metacarpophalangeal joints; radiocarpal and metacarpophalangeal involvement is rare – Destruction without bony proliferation; no cystic lesions – Mutilating arthritis is possible

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Radiography The most common finding in scleroderma of the hand is a combination of acro-osteolyses and calcinoses. In Sharp syndrome, there is also articular malalignment. About one-third of patients have pathologic findings in the radiographs of the hands within the first six months of the disease (Table 39.3, Figs. 39.3–39.5).

arthritis has no soft-tissue calcifications. Acro-osteolyses in hyperparathyroidism or after a thermal trauma must be excluded. Due to the soft-tissue calcifications, dermatomyositis, hyperparathyroidism, and pseudohypoparathyroidism, as well as congenital hypoparathyroidism, calcium phosphate deposits in dialysis patients, tumorous calcinosis, and hypervitaminosis D must also be excluded.

Differential Diagnosis

Therapeutic Options

The multitude of pathologic findings in scleroderma explains the following differential-diagnostic considerations. Scleroderma also displays symptoms similar to those of rheumatoid arthritis in 2.5 % of cases, especially since a combination of scleroderma and rheumatoid arthritis can occur in an overlapping syndrome. Psoriatic

Calcium antagonists, ACE inhibitors, and calcitonin are administered to improve the microcirculatory perfusion. In the highly acute courses of sclerodermia with arthritis, serositis, and myositis, anti-inflammatory corticosteroids and immunosuppressive drugs such as azathioprine, cyclophosphamide, and chlorambucil, are used.

Polymyositis and Dermatomyositis Pathoanatomy and Clinical Symptoms

Radiography

A cell-mediated immune reaction against transversestriated muscle fibers causes a rapidly progressing, symmetric weakness of the proximal muscle groups of the pelvis and shoulders. In 20–40 % of cases there are typical erythematous and edematous lesions in the skin of the face, the neck, and the thorax, as well as on the extensor sides of the extremities and fingers. Concomitant arthralgias and Raynaud phenomenon can also appear. Pulmonary fibrosis, pericarditis, and myocarditis are variable.

The arthralgias occur in the knees and, above all, on the joints of the hands, occasionally even before myalgia. The symptoms are generally transitory and symmetric. Direct signs of arthritis are seldom seen in radiographs (Table 39.4, Fig. 39.6). Juvenile dermatomyositis, which occurs in 7 % of cases, can cause local disturbances in growth and development, so-called dermatomyositic dwarfism. Fifteen percent of patients with dermatomyositis develop malignant tumors.

Table 39.4 Radiographic signs of polymyositis and dermatomyositis U U

U

U

Soft-tissue swelling, later soft-tissue atrophy Calcifications: – Subcutaneous, plaquelike: common, but unspecific, can be combined with acroosteolyses – Streaky along fascia and muscle fibers – Rare, in large muscles almost pathognomonic Periarticular osteopenia: only occasional, also transient Erosive joint defects: occur sporadically, indicate an overlapping syndrome

Fig. 39.6 Radiographic findings in dermatomyositis. Plaquelike calcinosis interstitialis circumscripta on the middle and distal phalanges of the middle finger. There are also discrete acro-osteolyses on ungual tuberosities II, III, and V combined with spotty, periungual soft-tissue sclerosis. (Courtesy of G. Küffer, MD, Neumarkt.)

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Wegener Granulomatosis

Differential Diagnosis

Therapeutic Options

Differential diagnoses include rheumatoid arthritis, scleroderma, systemic lupus erythematosus, the overlapping syndromes, and hyperparathyroidism (where interstitial calcifications are not arranged in stripes).

These include immobilization and passive movement therapy. Corticosteroids are the drugs of first choice despite the danger of corticoid myopathy. Azathioprine, methotrexate, and immunoglobulins constitute secondchoice therapy. The benefit of plasmapheresis, radiation, or thymectomy has not been confirmed.

Panarteritis Nodosa Pathoanatomy and Clinical Symptoms

Differential Diagnosis

This systemic, necrotizing vasculitis primarily affects kidneys, mesenterial vessels, and blood vessels supplying muscles and nerves, causing complex organic symptoms. In approximataly 50 % of patients, arthralgias and myalgias of the hands, elbows, knees, and ankles will develop.

Radiography

Wegener granulomatosis, Henoch–Schoenlein purpura, giant-cell arteritis, and polymyositis must be taken into consideration. Arthritides and primary and secondary hypertrophic osteoarthropathies must also be considered because of their periosteal lesions.

Table 39.5 Radiographic signs of panarteritis nodosa

The generally asymmetric polyarthropathy progresses episodically. Skeletal symptoms can rarely be seen in radiographs (Table 39.5, Fig. 39.7).

U U

U

Polyarthritis without articular destruction Periosteal scleroses: – Diaphyseal on the small tubular bones – Lamellar or irregular – Comparable to hypertrophic osteoarthropathy Microaneurysms of the finger arteries: arteriographic evidence

Wegener Granulomatosis This necrotizing, granulomatous inflammation of the upper respiratory tract and the kidneys, as well as panarteritis nodosa, giant-cell arteritis, and Henoch–Schoenlein purpura, are classified as systemic vasculitides. In to 75 % of all patients, articular symptoms develop. Radiographically, joint lesions cannot be expected. At most, soft-tissue swelling, osteoporosis, and joint effusions are seen.

Fig. 39.7 Arteriogram of a hand affected by panarteritis nodosa. The late arterial contrast phase following administration of glyceryl trinitrate shows multiple aneurysms on the digitales communes et propriae arteries. (Courtesy of A. Beck, MD, Konstanz.)

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Sjögren Syndrome The classic symptoms are keratoconjunctivitis sicca and xerostomia (sicca complex) in combination with inflammatory systemic rheumatic disease (Sjögren triad) or with other collagenoses. Up to 50 % of cases are associated with rheumatoid arthritis (secondary Sjögren syndrome). The disease pattern on the hand corresponds to that of rheumatoid arthritis.

Further Reading Aigner RM, Fueger GF. Nuklearmedizinische Diagnostik. In: Brussatis F, Hahn K, eds. Nuklearmedizin in der Orthopädie. Heidelberg: Springer; 1990. Broich P, Jerusalem F. Polymyositis, Dermatomyositis und andere entzündliche Muskelerkrankungen. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:964–994. Dihlmann W. Gelenke-Wirbelverbindungen. 3rd ed. Stuttgart: Thieme; 1985:126–140. Dreher R. Über den Stellenwert der Gelenkszintigraphie in der Arthritisdiagnostik. In: Brussatis F, Hahn K, eds. Nuklearmedizin in der Orthopädie. Heidelberg: Springer; 1990. Fischer E. Soft tissue changes in the hands in progressive scleroderma (excluding calcifications). Fortschr Röntgenstr. 1987;146:200–206. Fogelman I, Maisey MN, Clarke SEM. An Atlas of Clinical Nuclear Medicine. 2nd ed. London: Martin Dunitz; 1994. Freyschmidt J. Gelenkerkrankungen. Heidelberg: Springer; 1985: 139–144.

Kappert A. Lehrbuch und Atlas der Angiologie. 12th ed. Bern: Huber; 1989. Klippel JH, Gerber LH, Pollak L, Decker JL. Avascular necroses in systemic lupus erythematosus. Silent symmetric osteonecrosis. Am J Med. 1979;67:83–89. Manaster BJ. Handbook of Skeletal Radiology. 2nd ed. St. Louis: Mosby; 1997:104–170. Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: Saunders; 2002. Schröder JO, Harten P, Euler HH. Systemischer Lupus erythematodes. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000: 909–953. Sollberg S, Krieg T. Systemische Sklerose. In: Miehle W, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000. Stoller DW. Magnetic Resonance Imaging in Orthopaedics & Sports Medicine. 2nd ed. Philadelphia: Lippincott-Raven; 1997:851–993. Szanto D. MCTD-syndrome (mixed connective tissue disease). Fortschr Röntgenstr. 1980;133:445–454. Uhl M. Radiology of the manual skeleton. 1. Inflammatory joint diseases and rheumatology. Radiologe. 1999;39:432–449. Uhl M. Radiology of the skeleton of the hand. 2. Degenerative joint diseases. Endocrine and metabolic bone diseases. Radiologe. 1999; 39:1083–1100. Weissman BN, Rappoport AS, Sosman JL, Schur PH. Radiographic findings in the hands in patients with systemic lupus erythematosus. Radiology. 1978;126:313–320. zum Winkel K. Nuklearmedizin. 2nd ed. Heidelberg: Springer; 1990.

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Infectious Arthritis S. Spindler-Thiele, R. Schmitt

Acute forms of arthritis occur as immunological reactions after infections or through hematogenous spread or direct infection of the joint, usually with bacterial, less commonly with tuberculous, viral, or

parasitic pathogens. Diagnostic imaging of the hand is discussed synoptically for etiologically and pathophysiologically different articular infections along with their clinical and laboratory findings.

Pathways of Infection

Pathoanatomy and Clinical Symptoms Infectious arthritis usually involves monoarticular inflammation caused directly by pathogens with cartilaginous and bony destruction and can lead to fibrous or osseous ankylosis. Staphylococci are the most common pathogens in 70 %. Streptococci and Haemophilus influenzae are found in children, Neisseria gonorrhoeae in young women, and Gram-negative rods especially in patients with an immune deficiency. In principle, reactive arthritis, which breaks out after a latency period following an infectious disease, must be differentiated from infectious forms of arthritis. The following pathogens have been identified in the synovium or joint fluid recently: Chlamydia, Borrelia burgdorferi (Lyme disease), Mycobacterium leprae, Schistosoma haematobium (bilharziosis), and various viruses, especially hepatitis B and rubella. The discussion of whether infectious arthritis occurs in parallel with or complementary to an immunological pathogenesis is ongoing.

Organisms can enter a joint in different ways (Fig. 40.1): U Hematogenous spread of pathogens: The organisms reach the synovial membrane directly via the circulation or indirectly from an epiphyseal or periarticular focivia connecting vessels. Metastatic spread is especially common in the carpal joints. U Spread of infection through tissues: The inflammation spreads from soft tissues either through the joint capsule or along the tendon sheaths into the joint cavity so that the articular access can be relatively far from the arthritic focus. An osteomyelitic infection can penetrate into the joint via the destroyed articular cartilage. U Direct implantation: The infection arises after surgical opening of the joint or an injury that has penetrated the joint.

a

b c

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Fig. 40.1 a–c Dissemination pathways of infection in the hand. a Direct implantation of the pathogen into the joint (often in the metacarpophalangeal joint). b Dissemination of articular infection from the tendon sheath. The palmar plate and joint capsule must be passed on their margins. c Dissemination from the tendon sheath in the palm, from which osseous infections often originate.

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Ultrasonography

Diagnostic Imaging Radiography The stages of so-called soft-tissue signs, collateral signs (periarticular osteopenia), and direct signs of arthritis progress in acute, pyogenic arthritis in days to weeks (Fig. 40.2) and in a tuberculous articular infection in months to years. Without treatment, severe destruction and ankylosis develop.

Large joint effusions, articular and periarticular soft-tissue swelling (see Fig. 42.2), and concomitant soft-tissue abscesses can be identified with high-resolution ultrasonography (US).

Arthrography When a diagnostic joint puncture is performed to obtain pathogens, arthrography can also be performed to demonstrate defects in the articular cartilage or capsule.

Nuclear Medicine U

U

U

Three-phase skeletal scintigraphy with 99mTc phosphonates provides early detection of local hyperemia by radionuclide perfusion (phases I and II) and can differentiate to a certain extent between arthritis and osteomyelitis in phase III. Scintigraphy is useful in localizing the primary source of the infection, but differentiation between sterile and infectious arthritis is not possible. Inflammatory scintigraphy with 99mTc-HMPAO-labeled autologous leukocytes and Tc-nanocolloid, as well as Immunoscintigraphy with 99mTc-labeled murine monoclonal granulocytes or human unspecific immunoglobulin, selectively demonstrates acute granulocyteinduced inflammations. Aseptic or chronic forms of arthritis, such as tuberculous or leprous arthritis, generally cannot be located with either of these two procedures.

a Radiographic symptoms begin with carpometacarpal softtissue swelling and discrete decalcification of the capitate and metacarpals III and IV.

Computed Tomography CT scans can demonstrate not only osseous erosions in the joint, but also inflammatory soft-tissue thickening, but it is less sensitive than MRI. In infectious inflammations, CT is indicated to locate foreign bodies, as well as intraosseous and intra-articular air when radiographs prove unremarkable. Aside from US, CT can be useful in controlling the puncture of joints and abscesses.

b Two months later, a diffuse, partially spotty decalcification of the carpus and adjacent forearm and part of the metacarpus can be seen. The midcarpal joint space is now narrowed with focal demarcation of the subchondral bone plate and tiny erosive defects in the capitate.

Fig. 40.2 a, b Disease progression of acute staphylococcal arthritis of the carpals.

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Infectious Arthritis

As described in the chapters on noninfectious forms of arthritis (Chapters 34–39), MRI is the imaging procedure of choice for confirmation and staging of the spread of synovial joint diseases. Joint effusions, as well as the almost always concomitant bone-marrow and soft-tissue edemas, appear hyperintense in T2-weighted sequences (PD- or T2-weighted FSE, both fat-saturated, STIR/SPIR FSE). Cartilaginous defects caused by arthritis

can be visualized directly with a T2*-weighted GRE or a fat-saturated PD-weighted FSE sequence (Fig. 40.3 d). The inflamed soft tissues (synovium, joint capsules, ligaments, tendon sheaths) can be visualized in several (oblique) imaging planes. They usually show increased enhancement of intravenously administered gadolinium in T1-weighted SE sequences with fat suppression (Fig. 40.3 a, b). Concomitant osteomyelitis generally cannot be differentiated. MRI results mostly do not provide information on the etiology of the arthritic disease.

a

b

Magnetic Resonance Imaging

d

c Fig. 40.3a–d Acute bacterial arthritis and osteomyelitis. Clinical signs of inflammation two years after a gonococcal infection. Coronal T1-weighted SE images, a plain and b fat-suppressed, after administration of gadolinium reveal multicompartmental synovitis with effusions and bony erosions, advanced destruction of the radiocarpal and midcarpal articular cartilage, diffuse bonemarrow edema, and soft-tissue infiltration (especially on the ulnar side). The extent of the expanding joint effusions, as well as the erosions of bone and articular cartilage, can be seen synoptically in the sagittal T1-weighted SE plain sequence (c) and axial T2*-weighted GRE sequence (d).

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Disease Entities

Acute Bacterial Arthritis Pathoanatomy and Clinical Symptoms

Differential Diagnosis

Cuts, stabs, and bites cause infective arthritis, above all in the finger joints, by the direct inoculation of pathogens. Soft-tissue abscesses and phlegmons are spread proximally and distally via the tendon compartments. Wrist infections generally arise during sepsis with pronounced impairment of overall health. The three infective pathways of a pyogenic joint inflammation are represented on the hand (Fig. 40.1).

The traumatic spread of infectious arthritis can be clarified clinically. Septic, hematogenous arthritis of the carpus has a less consistent pattern of distribution than rheumatoid arthritis. Tuberculous arthritis progresses more slowly.

Radiography Radiographs depict soft-tissue, collateral, and direct signs of arthritis (Table 40.1, Fig. 40.2).

Therapeutic Options These include therapeutic (and diagnostic) punctures, articular flushing, arthroscopy, immobilization, and physiotherapy. Therapy is usually commenced even before the antibiogram results are known in order to prevent joint destruction. Antibiotic therapy consists of a dual combination applied intravenously during the first week, oral continuation of the dual therapy for another five weeks, and monotherapy for a further six weeks.

Tuberculosis of the Hand Pathoanatomy and Clinical Symptoms

destructive course. Tuberculosis of the tendon sheaths is rare (Chapter 42).

Tuberculosis of the hand comprises only 2–10 % of the renewed increase in skeletal manifestations of tuberculosis, affecting mostly adults. It is of hematogenous origin, either primarily osseous and spread to the adjacent joints or primarily synovial, and has an insidious, less

Table 40.1 Radiographic signs in acute bacterial arthritis U U

U U U

Extensive soft-tissue swelling and joint effusion Rapidly progressing osteopenia: – Subchondral and epiphyseal – Affects all carpals with recognizable destructive focus – Concomitant involvement of distal forearm metaphyses and proximal metacarpal sections Demarcation of the subchondral bone plate Narrowing of the joint space Coarse erosions and destructive collapses, ankyloses can appear

Radiography Radiographic signs of arthritis are not recognizable until 2–4 months after the commencement of clinical symptoms (Table 40.2, Fig. 40.4). Table 40.2 Radiographic signs of tuberculous arthritis U U U U

U

Periarticular osteopenia Indistinct subchondral bone plate Delayed narrowing of joint space Destruction and ankylosis are generally prevented today by effective therapy Peculiarities of tuberculosis of the hand: – Carpal tuberculosis: mainly affects the radial side (distal radius, scaphoid, trapezium, and capitate, and the bases of metacarpals II and III) – Cystic tuberculosis of the carpus: marginal punched-out defects (inflamed synovium) or central osseous defects (intraosseous, granulomatous) – Spina ventosa on small tubular bones in children: expansive destruction of cancellous and compact bone with thick periosteal shell

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Leprosy

Differential Diagnosis Pyogenic arthritis is clinically recognizable by its severe general symptoms and rapid progress. Cystic foci of skeletal sarcoidosis are more common on the fingers and display less local inflammation. Osteonecroses and enchondromas must also be taken into consideration.

Therapeutic Options The microscopic confirmation of acid-fast rods in a smear of the material obtained by puncture succeeds in only 20 % of cases. They can be identified in culture in 80 % of cases and in over 90 % histologically from a synovial biopsy. Therapy is the same as for pulmonary tuberculosis, beginning with a combination of isoniazid, rifampin, and pyrazinamide for two months and continuing with isoniazid and rifampin for another 4–10 months. When the complications of osteomyelitis, osteonecroses, and fistula are present, surgical débridement must be performed.

Syphilis

Fig. 40.4 Tuberculous arthritis of the carpals. Advanced destruction, collapse, and ankylosis of the carpus. The cystic (granulomatous) radiolucencies in the radial epiphyses and in the base of metacarpal V, the indistinct joint contours, and the carpal soft-tissue swelling indicate a florid inflammatory process. (Courtesy of P. Hahn, MD, Bad Rappenau.)

The pathogenesis and radiographic appearance of tertiary syphilis resemble tuberculous arthritis.

Gonococcal Arthritis Mostly monoarticular infectious arthritis, which, among other joints, predominantly affects the carpal joints, can develop about two weeks after the venereal infection (Fig. 40.3). Polyarticular symptoms are observed in gonococcal sepsis only.

If no gonococci are found in the synovium, one should assume the presence of reactive arthritis or postgonorrheal Reiter syndrome.

Leprosy Combinations of neural, osseous, and dermal complications determine the clinical presentation: U Neural leprosy: This is found especially on the hands and feet. The radiographic findings are dominated by osteopenia, pathologic fractures, and areactive acroosteolyses (“penciled” appearance). Charcot joints are rare. U Arthritis associated with leprosy: This is actually an infectious arthritis of hematogenous origin or is spread from granulomatous lepromatous foci in the bone

U

U

marrow and surrounding soft-tissues. Destructiveerosive polyarthritis predominantly affects carpal, metacarpophalangeal, and proximal interphalangeal joints. Reactive arthritis: This is often combined with erythema nodosum leprosum and is manifested as symmetric, peripheral polyarthritis. Superinfections often dominate the radiographic morphology of the phalanges with circumscribed decalcification and coarse destruction.

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Lyme Arthritis After a latency of weeks to months, acute intermittent and rapidly migrating arthralgias arise, though there are usually no radiographic symptoms. This occurrence was

first interpreted as reactive arthritis until spirochetes were identified in the synovium in 1985. Chronic-erosive arthritis can occur after months to years.

Bilharziosis Arthropathy The joints of the lower extremities are affected by the infectious or reactive form of the disease. There is no specific radiographic finding.

Viral Arthritides (Hepatitis B, Rubella, Mumps, Variola, Parvo-B19, Vaccinia) The metacarpophalangeal and proximal interphalangeal joints are predisposed sites. Episodic, generally symmetric polyarthritis is observed, which usually heals without sequela and without becoming chronic. Long-standing

disease can lead to a carpal tunnel syndrome. Osteomyelitis variolosa of the hand is rare but tends to spread to the joints and become superinfected. Virus-related growth disturbance can be a associated.

Fungal Arthritis Essentially rare fungal infections with osseous manifestation or a self-limited, acute polyarthritis appear with varying incidence. The arthritis can be spread from subchondral osseous foci or by the circulating blood, or can arise from traumatic inoculation. North- and SouthAmerican blastomycosis, African histoplasmosis, ubiquitous cryptococcosis and spirotrichosis, Indian Madura mycosis, and the extremely rare osseous candidiosis are known. None of these disease entities has a specific radiographic appearance.

Further Reading Atkin SL, El-Ghobarey A, Kamel M, Owen JP, Dick WC. Clinical and laboratory studies of arthritis in leprosy. Br Med J. 1989;124: 1423–1425. Aigner RM, Fueger GF. Nuklearmedizinische Diagnostik. In: Brussatis F, Hahn K, eds. Nuklearmedizin in der Orthopädie. Heidelberg: Springer; 1990. Bassiouni M, Kamel M. Bilharzial arthropathy. Ann Rheum Dis. 1984; 43:806–809. Chandnani VP, Beltran J, Morris CS et al. Acute experimental osteomyelitis and abscesses: Detection with MR imaging versus CT. Radiology. 1990;174:233–236. Dihlmann W. Gelenke-Wirbelverbindungen. 3rd ed. Stuttgart: Thieme; 1985:135. Eckel H, Düe K. Tuberculosis of the smaller joints. Fortschr Röntgenstr. 1985;142:19–23. Enna CD, Jacobson RB, Rausch RO. Bone changes in leprosy: A correlation of clinical and radiographic features. Radiology. 1971;100: 295–299. Feldmann F, Auerbach R, Johnson A. Tuberculous daktylitis in the adult. Am J Roentgenol. 1971;112:460–479. Fogelman I, Maisey MN, Clarke SEM. An Atlas of Clinical Nuclear Medicine. 2nd ed. London: Martin Dunitz; 1994. Graif M, Schweitzer ME, Deely D, Matteucci T. The septic versus nonseptic inflamed joint. MR characteristics. Skeletal Radiol. 1999;28: 616–620. Hausman MR, Lisser SP. Hand infections. Orth Clin North Am. 1992;23: 171–185. Herzer P. Lyme-Borreliose. In: Miehle W, Fehr K, Schattenkirchner M, Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:742–748. Hopkins KL, Li KCP, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. 1995:24:325–330.

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Fungal Arthritis

Hsu CY, Lu HC, Shih TT. Tuberculous infection of the wrist: MRI features. Am J Roentgenol. 2004;183:623–628. Jaovisidha S, Chen C, Ryu KN et al. Tuberculous tenosynovitis and bursitis: Imaging findings in 21 cases. Radiology. 1996;201:507–513. Jbara M, Patnana M, Kazmi F, Beltran J. MR imaging: Arthropathies and infectious conditions of the elbow, wrist, and hand. Magn Reson Imaging Clin N Am. 2004;12:361–379. Lawson JP, Steere AC. Lyme arthritis: Radiologic findings. Radiology. 1985;154:37–43. Luzar MJ, Caldwell JH, Mekhjian H, Thomas FB. Yersinia enterocolitica infection presenting as chronic enteropathic arthritis. Arthrit Rheum. 1983;26:1163–1165. Manaster BJ. Handbook of Skeletal Radiology. 2nd ed. St. Louis: Mosby; 1997:104–170. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. 1998;14: 579–587. Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: Saunders; 2002. Schlumpf U, Vogt M. Gelenkinfektionen und Arthritiden bei Infektionskrankheiten. In: Miehle W, Fehr K, Schattenkirchner M,

Tillmann K, eds. Rheumatologie in Praxis und Klinik. Stuttgart: Thieme; 2000:753–777. Schneider P. Viral arthritides in man. Münch med Wschr. 1981;123: 1891–1894. Stoller DW. Magnetic Resonance Imaging in Orthopaedics & Sports Medicine. 2nd ed. Philadelphia: Lippincott-Raven; 1997:851–993. Sueyoshi E, Uetani M, Hayashi K, Kohzaki S. Tuberculous tenosynovitis of the wrist: MRI findings in three patients. Skeletal Radiol. 1996:25:569–572. Tsai E, Failla JM. Hand infections in the trauma patient. Hand Clin. 1999;15:373–386. Uhl M. Radiology of the manual skeleton. 1. Inflammatory joint diseases and rheumatology. Radiologe. 1999;39:432–449. Uhl M. Radiology of the skeleton of the hand. 2. Degenerative joint diseases. Endocrine and metabolic bone diseases. Radiologe. 1999; 39:1083–1100. Wollenhaupt HJ, Schneider C, Zeidler H, Krech T, Kuntz BM. Clinical and serological characterization of Chlamydia-induced arthritis. Dtsch med Wschr. 1989;114:1949–1954. Yurdakul S, Yacici H, Tüzün Y et al. The arthritis of Behcet’s disease: A prospective study. Ann Rheum Dis. 1983;42:505–515.

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Inflammatory Diseases of the Bones and Soft Tissues 41 Osteomyelitis .

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42 Infections of the Soft Tissues

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Osteomyelitis H. Rosenthal, R. Schmitt, J. Spitz

Osteomyelitides can be classified according to pathogens, sites of entry, and the clinical course of the disease. Radiographic morphology only rarely indicates the pathologic organism. The clinical findings are required to identify a “moth-eaten” or permeative osteolysis as osteomyelitis. The exposure of the hand to traumatic inoculation of pathogens and the possibility of infection spreading through the tendon sheaths, fasciae, and lymphatic vessels explains the

Confirmation of osseous infection is important for planning surgical intervention.

Introduction Infections of the soft tissues of the hand require a precise diagnosis and immediate therapeutic decision to prevent spread along predefined anatomic pathways. Osteomyelitis of the hand is usually the result of a soft-tissue infection or, less often, hematogenous dissemination.

Diagnostic Imaging Radiography Acute courses of osteomyelitis lead to osteolytic destruction. The radiographic signs include initially focal decalcification and periosteal reaction (Fig. 41.1 a). Inflammatory focal osteolyses appear later (Fig. 41.1 b), and osteosclerosis appears in chronic stages (Table 41.1). The term “early signs” should not conceal the fact that 8–10 days usually pass before osteomyelitis can be identified in radiographs. Conventional tomography offers hardly any advantages in diagnosis of inflammation of the hand in comparison to survey views (or the use of the magnification technique if necessary).

U U

U U

frequency of secondary osteomyelitides of the hand. In contrast, hematogenous osteomyelitis is rare. Radiographs provide the imaging basis for the detection of inflammatory lesions. MRI is the method of choice to determine the extent of inflammation in the bone marrow and the surrounding soft tissue. CT is useful to identify a sequestrum, granulation tissue, involucrum and an intraosseous abscess in chronic osteomyelitis.

Computed Tomography Sequester, granulation tissue, involucrum and an intraosseous abscess can be detected reliably in conventional tomography or CT (Fig. 41.4). a

b

Fig. 41.1 a,b Osteomyelitis of different origins and in various stages. a Early signs of osteomyelitis on the proximal phalanx of the thumb in a massive soft-tissue infection. Evidence of periosteal thickening and discrete erosions in the compact bone (arrows). b Advanced stage of hematogenous osteomyelitis of the third middle phalanx. Moth-eaten osteolysis on the radial side along with periarticular osteopenia and soft-tissue swelling.

Table 41.1 Radiographic signs of osteomyelitis U

U

U

Early stage – Discrete decalcification – Mild periosteal reaction Destructive stage – Motheaten or permeative osteolyses Chronic stage – Concomitant osteosclerotic lesions

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Osteomyelitis

Ultrasonography Inflammatory involvement of the soft tissues and joints in osteomyelitis can reliably be confirmed with US.

Magnetic Resonance Imaging This procedure best determines the extent of bonemarrow infiltration and concomitant soft-tissue infec-

tion. Intraosseous and extraosseous inflammatory areas appear hypointense in T1-weighted sequences. After administration of gadolinium, signal intensity increases in vascularized granulation tissue (Figs. 41.2, 41.3). Sequestra, however, show no enhancement. Because of their high contrast, fat-suppressed T2-weighted and STIR sequences are useful to identify bone-marrow edema. MRI is currently the method of choice to determine the complete extent of osteomyelitis.

Fig. 41.2 a, b Hematogenous osteomyelitis of the carpus after a purulent infection of the paranasal sinuses.

a Multiple signal alterations are seen in the entire carpus in a plain T1-weighted SE sequence. The distal section of the forearm is not affected.

a

b Administration of gadolinium reveals diffuse inflammatory enhancement of the bone marrow and concomitant synovitis (T1-weighted SE sequence with fat saturation).

b

c

Fig. 41.3 a–c Posttraumatic osteomyelitis after previous internal fixation of a radius fracture. a The radiograph shows signs of deforming and sclerosing b, c Plain and enhanced MR images display a florid stage of osteomyelitis on the radius and the ulna. Widespread inflammation in the distal section of the radius and the ulna, periosteal reaction. Defects of the radius epiphysis and on as well as in the surrounding soft tissues. Marked contrast the ulna head. enhancement in these compartments.

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Nuclear Medicine

b

a Fig. 41.4 a, b Osteomyelitis with sequestrum after open fracture of the finger. a Sagittal CT scan identifies a sequestrum surrounded by an osteolytic cavity in the third proximal phalanx. Sclerosing osteitis of an involucrum and cortical defect on the palmar side. b Axial multiplanar reconstruction of the CT data-set clearly demonstrating the sequestrum.

If the results of three-phase skeletal scintigraphy are unremarkable, a florid inflammatory process in the hand skeleton can be largely excluded. Increased nuclide uptake in the presence of osteomyelitis is unspecific, however (Fig. 41.6 a): U Differentiation between a posttraumatic process and an inflammatory process is not possible with nuclear medicine because in both inflammation and callus formation, there is an increased production of fibrous bony tissue and, thereby, an increased content of amorphous calcium phosphate with increased binding of the radiopharmaceutical substance. This is also the case for four-phase scintigraphy. U Up to six months after a trauma or surgery of the bones, leukocytic scintigraphy cannot differentiate between reparative remodeling processes and inflammatory ones. In chronic osteomyelitis, nuclide uptake of labeled granulocytes is in any case limited because of the underlying pathophysiology. U Gallium scintigraphy, which is preferred in AngloAmerican reports, has not yet reached acceptance in Europe. Labeled human immunoglobulins, which are under clinical evaluation, do not provide any more essential information than leukocyte scintigraphy. Alternatively, 99mTc-labeled nanocolloid, which leads to extravasation of the nuclide as a result of increased vascular permeability in inflammatory tissue, can be used.

Disease Entities

Hematogenous Osteomyelitis Pathoanatomy and Clinical Symptoms

Diagnostic Imaging

Acute hematogenous osteomyelitis is rare in the skeleton of the hand. The primary focus of infection often remains clinically unknown. The spectrum of pathogens varies according to age, and essentially all organisms can be found. Hematogenous osteomyelitis appears predominantly in the distal sections of the radius and ulna during growth when the epiphyseal plates are still open. The osseous infection usually originates in the metaphysis, where bacterial implantation is promoted by the slow blood circulation in the venous sinusoids. Edema and an accumulation of pus cause increased pressure and slowing of the blood circulation and lead to osteonecrosis. Reactive new periosteal bone formation surrounds the infected, necrotic bones.

Radiography Radiographs show “moth-eaten” osteolyses (Fig. 41.1 b), which are accompanied by periosteal reactions and, less often, by sequestra during disease progression. If acute hematogenous osteomyelitis does not heal, chronic osteomyelitis develops, which demonstrates more severe osteosclerosing remodeling in radiographs. Even primary development of chronic sclerosing osteomyelitis is possible.

Nuclear Medicine Skeletal scintigraphy is suitable to exclude or confirm the presence of osteomyelitis before lesions can be detected in plain radiographs, especially if MRI is not available.

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Tuberculous Osteomyelitis

Magnetic Resonance Imaging MRI is the procedure of choice for primary diagnosis, planning of therapy, and follow-up. It provides information on the extent of osteomyelitis and concomitant soft-

tissue complications (Fig. 41.2). Abscesses and sequestra can be delineated with fat-saturated T1-weighted sequences after administration of gadolinium.

Tuberculous Osteomyelitis Pathoanatomy and Clinical Symptoms

Diagnostic Imaging

Tuberculous osteomyelitis, which has a special clinical course among hematogenous infections, is manifested relatively often in the bones of the hand, including the carpus, in comparison to other pathogens. Bone involvement develops as post-primary tuberculosis; concomitant active pulmonary disease at the time of diagnosis is seen in only a minority of cases. The disease is not limited to growing children and adolescents. Transitions to tuberculous arthritis (Fig. 40.4) with subsequent ankylosis have been observed.

Radiography “Honeycombing,” “moth-eaten” osteolyses (Fig. 41.6), sequestra, and an increase in volume are visible in radiographs. Periosteal reactions remain mild. During childhood, spina ventosa (in which the affected short tubular bones appear thickened and vesicular) is characteristic (Fig. 41.5).

Magnetic Resonance Imaging Tuberculous osteomyelitides often display an intense, ring-shaped contrast enhancement after application of intravenous gadolinium.

Fig. 41.5 Tuberculous osteomyelitis in a 10-month-old child. Characteristic spina ventosa with increased volume, oval osteolysis, and thickened compact bone of the first metacarpal. a

b

Fig. 41.6 a, b Acute tuberculous osteomyelitis of the distal portion of the radius after pulmonary tuberculosis. a Skeletal scintigraphy shows intensive nuclide uptake in the radius epiphysis. b In the same location, the radiograph reveals an indistinctly demarcated osteolysis. No osteosclerotic reaction. Probably inactivity osteopenia of the carpus.

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Secondary Osteomyelitides Phalangeal Osteomyelitis Pathoanatomy and Clinical Symptoms Phalangeal manifestation is by far the most common form of osteomyelitis of the hand. The purulent inflammation is usually caused by local inoculation of pathogens during an injury, whereby the organisms can reach the periosteum or bones directly. Generally, however, a soft-tissue infection like a paronychia and felon develops first and secondarily leads to an osteomyelitis. The distal phalanx is most often affected. The infection in the hand spreads via the tendon sheaths, fasciae, and lymphatic vessels to the middle and proximal phalanges. The formation of sequestra is not uncommon or of special importance for therapy because they can maintain chronic fistulas.

Magnetic Resonance Imaging Just as in hematogenous osteomyelitis, MRI is especially useful in the diagnosis of inflammatory soft tissues, which are also always affected and must be evaluated for planning of therapy. The vast majority of cases of paronychias and felons do not involve the bones, so that MRI is also useful to exclude osteomyelitis.

Posttraumatic Osteomyelitis Open fractures and occasionally even surgery can result in a posttraumatic osteomyelitis (Figs. 41.3, 41.4). Positive radiographic findings cannot be expected before 12 days after the injury.

Bites Pathoanatomy and Clinical Symptoms

Diagnostic Imaging Radiography The diagnostic criteria in Table 41.1 apply. Examples can be found in Figs. 40.2 and 41.1 b. The radiographic examination must include a search for foreign bodies.

Bites on the hand have a high rate of complications. Among the inflammatory complications, in addition to soft-tissue infection and bacterial arthritis, are osteomyelitides. Dog bites are more common than those from cats, rodents, and humans. Any bite inoculates aerobic and anaerobic organisms.

Computed Tomography The use of CT is mainly limited to chronic, sclerosing forms of osteomyelitis and to identifying sequestra and intraosseous abscesses composed of pus and necrotic bone tissue.

Radiography Occasionally, only minimal bony lesions caused by the bite can be identified immediately after the injury. Early radiographic signs of bone or joint infection first appear after about 8–10 days (Fig. 40.1).

Special Forms of Osteomyelitis Plasma-cell Osteomyelitis, Brodie Abscess, Garré Chronic Sclerosing Osteomyelitis All three infectious processes are chronic forms of osteomyelitis and display different extents of osteosclerosing lesions in radiographs. A pathogen usually cannot be isolated in plasma-cell osteomyelitis and in chronic sclerosing osteomyelitis (Fig. 41.7). These three forms rarely appear on the hand.

Osteomyelitides Caused by Rare Organisms Several infectious tropical diseases can cause polyostotic bone lesions, which sometimes have a cystic, honeycombed, or even erosive appearance. Examples are histoplasmosis, mycetoma, sporotrichosis, and coccidioidomycosis. Leprosy can be manifested in the hand as osteitis leprosa multiplex cystica. When there are unusual forms of multiple osteolyses in the hand, the rare diseases of this group should be taken into consideration as differential diagnoses.

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Special Forms of Osteomyelitis

Chronic Recurrent Multifocal Osteomyelitis This variant of osteomyelitis is a disease of childhood and youth in which several osteomyelitic foci appear synchronously or metachronously. Pathogens are usually not identified. Immunological phenomena associated with infection and a genetic predisposition have been discussed as playing a role in the causation. In radiographs, osteosclerotic transformation is usually dominant in comparison to lytic lesions (Fig. 41.8). The inflamed foci, which sometimes show a paucity of symptoms, can be identified with certainty scintigraphically. The disease course is protracted but benign. Contrast-enhanced MRI is well suited to following-up of inflammatory activity.

Fig. 41.7 Chronic sclerosing osteomyelitis in the distal radius section. Fusiform distension and inhomogeneous, mainly dense, osteosclerosis in the diametaphyseal transition zone. Thinning of the compact bone. No evidence of pathogens in the bonemarrow, which was surgically cleaned out.

Fig. 41.8 a, b Chronic, recurrent multifocal osteomyelitis in a 3-year-old girl. a Osteomyelitic destruction in the metaphysis of the distal radius, the ulnar notch included. Diffuse osteosclerosis and periosteal reaction on the ulnar side. b A few weeks later, osteomyelitis is seen in the metaphysis of the left distal tibia.

a

b

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Differential Diagnosis If inflammatory signs are initially absent, “moth-eaten” or permeative lesions in osteomyelitis located in the diaphysis must be differentiated from Ewing sarcoma, and such changes in the metaphysis must be differenti-

ated from osteosarcoma. These tumors, as well as osseous spread of a soft-tissue sarcoma, are very rare on the hand.

Therapeutic Options The basis for successful surgical treatment of osteomyelitis is complete extirpation of the nonviable bone. This especially includes sequestra and surrounding necrotic tissue. These damaged areas are not reached by antibiotics because of their absent or only minimal vascularization, resulting in a continuation of the bacterial colonization. Sufficient immobilization must also be ensured with external stabilization. This is usually achieved with an external fixator or with special splints. The use of the appropriate antibiotic is also essential. The resulting defects in soft tissues and bones can be treated with distraction or covered with a microvascular flaps.

Further Reading Baek GH, Chung MS. Methicillin-resistant Staphylococcus aureus osteomyelitis of the scaphoid from a catheter in the radial artery. Bone Jt Surg. 2002B;84:273–274. Barbieri RA, Freeland AE. Osteomyelitis of the hand. Hand Clin. 1998; 14:589–603. Benkeddache Y, Gottesman H. Skeletal tuberculosis of the wrist and hand: A study of 27 cases. J Hand Surg. 1982;7:593–600. Bonakdapour A, Gaines VD. The radiology of osteomyelitis. Orthop Clin N Am. 1983;14:21–37. Brown T, Wilkinson RH. Chronic recurrent multifocal osteomyelitis. Radiology. 1988;166:493–496. De Smet L, Fabry G. Primary subacute osteomyelitis of the wrist in children. Acta Orthop Belg. 1995;61:282–285. Chandnani VP, Beltran J, Morris CS et al. Acute experimental osteomyelitis and abscesses: Detection with MR imaging versus CT. Radiology. 1990;174:233–236. Dangman BC, Hoffer FA, Rand FF. Osteomyelitis in children: Gadolinium-enhanced MR imaging. Radiology. 1992;182:743–747. Demharter J, Bohndorf K, Michl W, Vogt H. Chronic recurrent multifocal osteomyelitis: radiologic and clinical investigations of five cases. Skeletal Radiol. 1997:26:579–588. Durbin M, Randall RL, James M, Sudilovsky D, Zoger S. Ewing’s sarcoma masquerading as osteomyelitis. Clin Orthop. 1998;357: 176–185. Erdman WA, Tamburro F, Jayson HT, Weatherall PT, Ferry KB, Peshock RM. Osteomyelitis: Characteristics and pitfalls of MR imaging. Radiology. 1991:180:533–539. Feldmann F, Auerbach R, Johnson A. Tuberculous dactylitis in the adult. Am J Roentgenol. 1971;112:460–479. Fletcher BD, Scoles PU, Nelson AD. Osteomyelitis in children: detection by magnetic resonance. Radiology. 1984;150:57–60. Gericke M, Eckart L, Göke U, Panhorst J, Felix R. 3 Phase scintigraphy with nanocolloids and anti-granulocytes-ab in acute and chronic posttraumatic septic osteomyelitis. Eur J Nucl Med. 1990; 16(Suppl):174.

Germann G, Petracic A, Wittemann M, Raff T. Hematogenous osteomyelitis of the hand skeleton in adults after dental maxillary infections. Ann Plast Surg. 1996;37:106–110. Gold RH, Hawkins RA, Katz RD. Bacterial osteomyelitis: Findings on plain radiography, CT, MR and scintigraphy. Am J Roentgenol. 1991; 157:365–370. Gonzalez MH, Papierski P, Hall RF. Osteomyelitis of the hand after a human bite. J Hand Surg. 1993;18A:520–522. Gross T, Kaim AH, Regazzoni P, Widmer AF. Current concepts in posttraumatic osteomyelitis: A diagnostic challenge with new imaging options. J Trauma. 2002;52:1210–1219. Jurriaans E, Singh NP, Finlay K, Friedman L. Imaging of chronic recurrent multifocal osteomyelitis. Radiol Clin North Am. 2001;39: 305–27. Hausman MR, Lisser SP. Hand infections. Orth Clin North Am. 1992;23: 171–185. Hopkins KL, Li KCP, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. 1995:24:325–330. Jacobson AF, Harley JD, Lipsky BA, Pecoraro RE. Diagnosis of osteomyelitis in the presence of soft tissue infection and radiographic evidence of osseous abnormalities: Value of leukocyte scintography. Am J Roentgenol. 1991:157:807–812. Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T. Osteomyelitis and septic arthritis in children: Appropriate use of imaging to guide treatment. Am J Roentgenol. 1995:265:399–403. Kaim AH, Gross T, von Schulthess GK. Imaging of chronic posttraumatic osteomyelitis. Eur Radiol. 2002;12:1193–1202. Keret D, Giladi M, Kletter Y, Wientroub S. Cat-scratch disease osteomyelitis from a dog scratch. J Bone Joint Surg. 1998;80B: 766–767. König S, Aigner N. Bite wounds and their characteristic position in trauma surgery management. Handchir Mikrochir Plast Chir. 1995; 27:17–21. Kothari NA, Pelchovitz DJ, Meyer JS. Imaging of musculoskeletal infections. Radiol Clin North Am. 2001;39:653–671. McLain RF, Steyers C, Stoddard M. Infections in open fractures of the hand. J Hand Surg. 1991;16A:108–112. Mende B, Stein G, Kreysel HW. Bone changes in Hansen’s disease. Fortschr Röntgenstr. 1985;142:189–1992. Morrison WB, Schweitzer ME, Bock GW et al. Diagnosis of osteomyelitis. Utility of fat-suppressed contrast-enhanced MR imaging. Radiology. 1993:189:251–257. Papos M, Barat F, Narai G, Dillmann J, Lang J, Csernay L. Tc-99m HMPAO leukocyte and Tc-99m nanocolloid scintigraphy in posttraumatic bone infection. Clin Nucl Med. 1998;23:423–428. Quinn SF, Murray W, Clark RA, Cochran C. MR imaging of chronic osteomyelitis. J Comp Assist Tomogr. 1988;12:113–117. Reilly KE, Linz JC, Stern PJ, Giza E, Wyrick JD. Osteomyelitis of the tubular bones of the hand. J Hand Surg. 1997;22A:644–539. Rieger H, Pennig D, Edel G, Brug E. Tuberculosis of the hand. Handchir Mikrochir Plast Chir. 1990;22:183–190. Sammak B, Abd El Bagi M, Al Shahed M et al. Osteomyelitis: A review of currently used imaging techniques. Eur Radiol. 1999;9:894–900.

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Therapeutic Options

Santiago Restrepo C, Gimenez CR, McCarthy K. Imaging of osteomyelitis and musculoskeletal soft tissue infections: Current concepts. Rheum Dis Clin North Am. 2003;29:89–109. Schauwecker DS. Osteomyelitis: Diagnosis with In-111-labeled leukocytes. Radiology. 1989;171:141–146. Schilling F, Kessler S. Chronic recurrent multifocal osteomyelitis— I. Review. Klin Pädiatr. 2001;213:271–276. Stevanovic MV, Mirzayan R, Holtom PD, Schnall SB. Mucormycosis osteomyelitis in the hand. Orthopedics. 1999;22:449–450.

Theranzadeh J, Wang F, Mesgarzadeh M. Magnetic resonance imaging of osteomyelitis. Crit Rev Diagn Imag. 1992;33:495–534. Tsai E, Failla JM. Hand infections in the trauma patient. Hand Clin. 1999;15:373–386. Vande Streek P, Carretta RF, Weiland FL, Shelton DK. Upper extremity radionuclide bone imaging: The wrist and hand. Semin Nucl Med. 1998;28:14–24.

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Infections of the Soft Tissues P. Hahn, R. Schmitt

Soft-tissue infections in the hand comprise paronychia, felons, pyogenic tenosynovitis, deep space infections of the palm, gangrenous infections, and acute calcium hydroxyapatite deposits. The diagnosis is usually made clinically. Skeletal scintigraphy allows early exclusion of concomitant osteomyelitis. Only soft-tissue calcifications and air inclusions can be

identified in survey radiographs. High-resolution ultrasonography (US) is the method of first choice to identify and estimate the extent of an infection. MRI should be applied if an abscess in the deep spaces of the palm is suspected or if there is spread into multiple compartments.

Pathoanatomy and Clinical Symptoms

Nuclear Medicine

Infections of the soft tissues of the hand comprise a heterogeneous group of diseases. A common cause of infection is a penetrating injury through which pathogenic organisms are inoculated into the soft tissues. Even the tiniest injuries are sufficient, such as tears in the paronychial tissue occurring during nail care. Since there are a number of anatomically demarcated, enclosed compartments in the hand, infections usually remain at their primary site of origin in initial stages; this includes the subcutaneous or deep spaces in the palm, the tendon sheaths, and the joints. Patients with a compromised immune system and/or sensory deficiency (as in diabetes mellitus and severe carpal tunnel syndrome) are predisposed to infection. The clinical symptoms include the classic signs of inflammation (redness, hyperthermia, swelling, pain, and functional impairment), though they cannot always be recognized in their full extent. The findings from the physical examination are often sufficient to make the final diagnosis.

Three-phase scintigraphy is well suited to confirm or exclude osseous involvement with the uptake of osteotrophic radioactive pharmaceuticals. Soft-tissue infections lead to regional hyperemia, which results in increased bone metabolism in the affected area. The resulting ratios usually do not exceed 3.0, as shown in animal experiments. Furthermore, increased nuclide uptake is rather diffusely distributed. If the bone is involved as a result of soft-tissue infections (periostitis, osteitis, osteomyelitis), circumscribed parts of the skeleton show a marked increase in nuclide uptake, indicating new bone formation, in the 24-hour scintigram.

Diagnostic Imaging

Ultrasonography High-resolution US is the method of choice in clinically unclear inflammatory conditions. Only probes of 10 MHz or more should be used. These can reliably determine whether an inflammatory process is already transformed into colliquation, i.e., an abscess. A further important indication is the search for infectious foreign bodies that cannot be seen in radiographs.

Radiography

Computed Tomography

Radiographic survey views in two planes, in low-kilovoltage radiography if necessary, can provide evidence of inflammatory involvement of the bony skeleton of the hand, e.g., phalangeal osteomyelitis or infectious arthritis. Soft-tissue calcifications are seen in acute calcium (hydroxyapatite) deposition, chondrocalcinosis (calcium pyrophosphate dihydrate deposition), and sometimes in tuberculosis of the tendon sheath.

CT is only rarely applied in the evaluation of soft-tissue inflammation. Intravenous administration of a contrast agent is an essential prerequisite for diagnosis of abscesses. A few minutes after contrast application, a ring-shaped enhancement in the periphery of an abscess appears without enhancement in the center. For the hand, axial slices using the spiral CT technique and image calculation with a soft-tissue kernel are recommended.

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Infections of the Fingertips and Paronychia

Magnetic Resonance Imaging MRI is the procedure offering the greatest diagnostic relevance in inflammatory processes in the soft tissues of the hand. Prerequisites for hand MRI are a high-resolution technique and venous administration of gadolinium. Axial slices with T2-weighted FSE sequences and contrast-enhanced T1-weighted SE sequences are most suit-

able to identify inflammation of the compartments of the deep spaces in the hand. The other spatial planes determine the extent of the inflammatory process in proximal and distal directions. The signal intensity and pattern of contrast enhancement differentiate between cellulitis and an abscess, a distinction that is essential for therapeutic decision.

Disease Entities

Infections of the Fingertips and Paronychia Pathoanatomy and Clinical Symptoms These involve inflammation of the cutaneous and subcutaneous tissues. The condition often follows a minimal injury, e.g., paronychia as an inflammation of the nail wall caused by a skin lesion occasioned in cutting the fingernails.

Radiography Radiographs that are centered on the clinical maximum of the infectious process can locate nonradiolucent foreign bodies that initially triggered the infection. They are also necessary to confirm or exclude the presence of osteomyelitis or infectious arthritis (Fig. 42.1). Table 42.1 summarizes the radiographic criteria.

Table 42.1 Radiographic signs of osteomyelitis and infectious arthritis U U U U

Focal decalcification Indistinctly demarcated erosions Osteolysis and destruction Indistinct subchondral bone plate in case of joint infection

a

b

Fig. 42.1 a, b Infectious arthritis after a deep cut. Inflammatory destruction of the proximal interphalangeal joint with periarticular decalcification and erosion of the subchondral bone plate. Periosteal reaction and marked soft-tissue swelling.

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Pyogenic Flexor Tenosynovitis Pathoanatomy and Clinical Symptoms Pyogenic tenosynovitis is caused by pathogens that either directly enter the circular tendon sheaths in the metacarpal area or fingers (penetrating injuries) or spread from subcutaneous abscesses. During clinical examination, there is pressure pain above the site of injury and pain over the proximal portion of the flexortendon sheath when pressure is placed on the palm. The often-described V-shaped phlegmon is rarely involved according to our personal experience, but we have observed phlegmons that have spread proximally from the thumb through the carpal canal. This appears clinically as a highly acute carpal tunnel syndrome resulting from compression of the median nerve.

pathologic in flexor tendons. Enclosed foreign bodies can be detected by means of dense echoes and distal acoustic shadow. They are usually found in the center of the infection.

Magnetic Resonance Imaging The same morphologic criteria apply as for tenosynovitis. The tendon sheath is swollen, and hyperintense in T2weighted sequences. There is generally an accompanying edema in the adjacent soft tissues. Intense enhancement of the inflamed synovium is characteristic (Figs. 42.3,

Diagnostic Imaging Radiography Radiographs serve to exclude concomitant osteomyelitis and/or arthritis and to detect foreign bodies.

Ultrasonography A focal or diffuse synovial thickening can be demonstrated (Fig. 42.2). The inflamed and thickened tendon sheath displays moderate echos and is neighbored by hypoechoic synovial fluid. This constellation is always

Fig. 42.2 Pyogenic flexor tenosynovitis after inoculation via a wood splinter. 7.5 MHz ultrasound probe. The flexor-tendon sheath is focally swollen with edema and hypoechoic at the level of the proximal interphalangeal joint. The enclosed wood splinter, which was removed surgically, appears as a hyperechoic inclusion (arrows).

c

a

b

Fig. 42.3 a–c V-shaped pyogenic tenosynovitis in flexor compartments I–V after a stab wound. a, b Coronal plain and contrast-enhanced T1-weighted SE sequence. The inflamed tendon sheaths of all finger flexors at the level of the metacarpus and the proximal phalanges become visible only after intravenous administration of gadolinium. c Axial PD-weighted FSE image with fat saturation shows involvement of the soft tissues of the distal forearm. Inflammatory edema in the Parona’s space, the pronator quadratus muscle, and the tendon sheath of the flexor pollicis longus muscle.

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Deep Space Infections in the Palm

a

b

c

d

Fig. 42.4 a–d Abscess in the flexor tendon sheaths of the index finger. a The axial T2*-weighted GRE sequence shows massive fluid retention in the tendon sheath and seperation of the superficial from the deep flexor tendons. b Inflammatory edema of the paratendinous soft tissues and the bone marrow of the middle phalanx, from which the flexor tendons are displaced. T2-weighted FSE sequence with fat saturation.

c, d Inflammatory contrast enhancement in the periphery of the tendon sheath abscess. The inflammation has spread to the metacarpal space. T1-weighted SE sequences plain and fat saturated after administration of gadolinium.

42.4). If only one tendon sheath is involved in the pyogenic process, there is no demarcated area with a hypointense center, i.e., an abscess. Diagnostic imaging in

three planes enables the extent of the pyogenic flexor tenosynovitis to be precisely determined.

Deep Space Infections in the Palm Pathoanatomy and Clinical Symptoms

Diagnostic Imaging

Infections of the deep spaces of the palm spread continuously from a primary superficial site of entry, which can already have healed, into the deep compartments. Although pain is almost always present, redness and swelling cannot always be identified during the clinical examination because of the tissue superficial to the affected spaces. For planning of therapy it is important to determine which compartment or compartments contain the abscess. The compartments comprising the deep spaces of the hand (Fig. 42.5) are listed in Table 42.2.

Table 42.2 Deep spaces of the hand U U U U U U

Thenar space Hypothenar space Carpal canal Metacarpal space Parona’s space Guyon’s canal

Radiography Radiographs do not usually provide sufficient information and are used only to exclude rare concomitant osteomyelitis.

Ultrasonography The ultrasonographic morphology of an abscess is an area with a hypoechoic to anechoic center with increased distal acoustic enhancement. Separating membranous septa are well visualized in US. The inflamed wall of granulation tissue in the periphery of the abscess has hyperechoic portions. The ultrasonographic pattern can vary with the age of the abscess. The extent of solitary, focal abscesses can be reliably determined with US. Small abscesses deep in the carpal canal are difficult to detect, however, because the superficially traversing flexor tendons cause acoustic absorption phenomena. When the

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inflammatory process has spread to several compartments, it is difficult to determine the extent of the abscess and to differentiate it from sympathetic effusions in the adjacent synovial spaces.

Computed Tomography Imaging characteristics of abscesses in CT are the central colliquative zone, which is hypodense (30–50 HU), as well as the surrounding wall of granulation tissue, which displays a ring-shaped contrast enhancement. Abscesses can be localized and their extent can be determined in CT imaging.

M

H

T

C

Magnetic Resonance Imaging Contrast-enhanced MRI undoubtedly provides the most precise determination of the size of an abscess. Its location within the deep compartments of the hand can easily be established in axial images, and the longitudinal extent can be determined in coronal and sagittal slices. The same criteria as in CT apply for abscess morphology in MRI. The center of the abscess is hypointense in T1weighted sequences and hyperintense in T2-weighted sequences (Fig. 42.6). Proof of the presence of an abscess

Fig. 42.5 Diagram of the deep recesses of the hand. Three-dimensional view with demonstration of the thenar (T) and hypothenar (H) spaces, the carpal canal (C), and the metacarpal (M) space.

c

a

b

d

Fig. 42.6a–c Multi-compartment abscess in the palm. The abscess, which shows peripheral contrast enhancement, extends from the metacarpal space via the carpal canal into the distal forearm. Central colliquation of the abscess. a, b Sagittal T1-weighted SE sequences plain and fat saturated after administration of gadolinium.

c, d Fat-saturated axial T2-weighted FSE image displays the inflammatory extent of the abscess in the carpal canal between the flexor retinaculum and the superficial flexor tendons, as well as on the palmar-radial side of the forearm.

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Tuberculosis of the Tendon Sheath

is the strong contrast enhancement only in the periphery after intravenous application of gadolinium. This pattern

of contrast enhancement differentiates an abscess from a phlegmon in MRI.

Tuberculosis of the Tendon Sheath Pathoanatomy and Clinical Symptoms On the hand, osseous and articular tuberculosis (Chapter 40.4) must be differentiated from tuberculosis of the tendon sheaths. The pathogen in both cases is Mycobacterium tuberculosis. Although tuberculous infections generally have decreased during recent decades, the incidence is currently beginning to rise again. Often there is only a doughy, painless swelling along the tendons and, on the hand, the symptoms and the findings in diagnostic imaging are uncharacteristic and not very conclusive. Therefore, the possibility of tuberculosis should be taken into consideration where there is an inflammatory constellation of unknown origin.

Foggy, low-contrast foci of calcifications are typical for tuberculosis of the soft tissues. On the hand, however, these are often not detectable in primary diagnosis as a result of overprojecting bone structures.

Ultrasonography In tuberculous tenosynovitis, the tendon sheaths are usually thickened. In comparison to non-tuberculous tenosynovitis, their contents have a hyperechoic internal structure.

Computed Tomography CT usually is not indicated. If it is performed for other reasons, foggy calcifications are seen within the thickened and hypodense tendon sheath.

Diagnostic Imaging Radiography

Magnetic Resonance Imaging

The criteria of tuberculous arthritis, which in the hand more often appears alone than in combination with involvement of the tendon sheaths, are listed in Table 40.2.

The tendon sheaths appear enlarged and swollen, especially in axial MRI slices (Fig. 42.7). This generally impressive image appears to contradict the relatively bland

a

b

c

Fig. 42.7a–c Tuberculous tenosynovitis in painless, doughy swelling of the palm and the wrist. a Hyperintense, space-occupying lesion around the tendons of b, c Coronal T1-weighted SE sequences before and after the flexor pollicis longus muscle and the superficial and deep administration of gadolinium show the extent and inflammafinger flexors. Axial T2*-weighted GRE sequence. tory activity of the communicating tenosynovitis in the metacarpus, the carpal canal, and the forearm.

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patient’s complaints. After administration of gadolinium, there is a marked synovial contrast enhancement. With this combination of clinical and imaging symptoms, one

must consider tenosynovial sarcoidosis as a differential diagnosis.

Acute Calcium Deposition The acute inflammatory deposition of calcium hydroxyapatite is accompanied by distinct soft-tissue infiltrations, as shown in the CT image in Fig. 34.11. This disease entity is described in greater detail in Chapter 34. The

predisposed sites of calcium hydroxyapatite deposition are around the trapeziometacarpal joint, the pisiform, and in the carpal canal.

Gangrenous Infection Pathoanatomy and Clinical Symptoms Gangrene refers to an infection of the soft tissues of the hand and forearm caused by gas-producing anaerobic pathogens, most commonly Clostridium perfringens. The infection spreads subcutaneously and along the fascial compartments. It is promoted by ischemia of muscles, which may precede the gangrenous infection. The most impressive symptoms are initially exquisite local tenderness and a rapidly spreading inflammation. A life-threat-

ening impairment of the general condition soon develops. Crepitation of the skin can be present, but does not confirm the diagnosis.

Radiography The radiographs characteristically show patchy air inclusions in the soft-tissue compartments, especially in the subcutaneous tissue. Imaging with the low-kilovoltage technique is advantageous.

Differential Diagnosis The following must be taken into consideration in softtissue infections of the hand: U Inflammatory processes associated with rheumatoid arthritis, seronegative arthritides, collagenoses, etc. can be differentiated from infections caused by pathogens through their pattern of distribution and clinical symptoms. U In soft-tissue infections of the hand associated with calcifications, the acute inflammatory process indi-

U

cates hydroxyapatite deposition. A chronic, insidious disease course is more typical of tuberculosis or inflammation in sarcoidosis. Imaging procedures can localize the inflammatory focus precisely within the soft-tissue compartments of the hand, but identification of pathogens is decisive for the definitive diagnosis.

Therapeutic Options Superficial infections can usually be treated conservatively or with minimal surgical intervention. Diagnostic imaging provides valuable information on which to base a therapeutic decision by excluding involvement of the deeper tissues when uncertainty exists and symptoms are atypical. Other infections generally require extensive

surgical treatment of the affected structures with débridement, lavage, and perhaps even placement of drug carriers. Surgery is indicated for acute calcium deposits only when there is danger of cutaneous perforation or if they cause an acute carpal tunnel syndrome.

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Therapeutic Options

Further Reading Albornoz MA, Mezgarzedeh M, Neumann CH, Myers AR. Ganulomatous tenosynovitis: A rare manifestation of tuberculosis. Clin Rheumatol. 1998;17:166–169. Beltran J. MR imaging of soft tissue infection. MRI Clin North Am. 1995;3:743–751. Burkhalter WE. Deep space infections. Hand Clinics. 1989;5:553–559. Carroll RE, Sinton W, Garcia A. Acute calcium deposits in the hand. J Am Med Assoc. 1955;422–426. Chen WS, Eng H. Tuberculous tenosynovitis of the wrist mimicking de Quervain’s disease. J Rheumatol. 1994;21:763–765. Freeland AE, Senter BS. Septic arthritis and osteomyelitis. Hand Clinics. 1989;5:533–552. Frenkel A, Front D. Osteomyelitis and soft-tissue infection: Differential diagnosis with 24 hour/4 hour ratio of Tc-99m MDP uptake. Radiology. 1987;163:725–729. Gunther SS, Levy CS. Mycobacterial Infections. Hand Clinics. 1989;5: 591–598. Hoffman KL, Bergman AG, Hoffman DK, Harris DP. Tuberculous tenosynovitis of the flexor tendons of the wrist: MR imaging with pathologic correlation. Skeletal Radiol. 1996;25:186–188. Hopkins KL, Li KCP, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol. 1995:24:325–330. Hsu CY, Lu HC, Shih TT. Tuberculous infection of the wrist: MRI features. Am J Roentgenol. 2004;183:623–628.

Tuberculous tenosynovitis and bursitis: imaging findings in 21 cases. Radiology. 1996;201:507–513. Jebson PJL. Infections of the fingertip. Hand Clin. 1998;14:547–555. Israel O, Gips S, Jerushalmi J, Jeffrey RB. Acute suppurative tendosynovitis of the hand: Diagnosis with US. Radiology. 1997;162: 172–174. Leung PC. Tuberculosis of the hand. Hand. 1978;10:285–291. Louis DS, Jebson PJL. Mimickers of hand infections. Hand Clin. 1998; 14:519–529. Neviaser RJ. Infections. In: Green DP, ed. Operative Hand Surgery. 3rd ed. Vol II. New York: Churchill Livingstone; 1993:1021–1038. Nevasier RJ. Tenosynovitis. Hand Clinics. 1989;5:525–531. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: Imaging appearance. Am J Roentgenol. 2002;178:557–62. Rahmouni A, Chosidow O, Mathieu D et al. MR imaging of acute infections cellulitis. Radiology. 1999:192:493–496. Rieger H, Brug E. Das Panaritium. Munich: Hans-Marseille-Verlag; 1992. Sagar VV, Piccone JM, Charkes ND. Studies of skeletal tracer kinetics: III. Technetium-99m-(Sn) methylene disphosphonate uptake in the canine tibia as a function of blood flow. J Nucl Med. 1979;20: 1257–1261. Snyder CC. Animal bite infections of the hand. Hand Clin. 1998;14: 691–711. Sueyoshi E, Uetani M, Hayashi K, Kohzaki S. Tuberculous tenosynovitis of the wrist: MRI findings in three patients. Skeletal Radiol. 1996; 25:569–572.

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Tumorous and Tumorlike Diseases of the Hand 43 Cystic Bone Lesions 44 Bone Tumors

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Cystic Bone Lesions N. Reutter, F. Fellner

Cystic bone lesions are usually round osteolytic destructions of the bone structure that appear either as a independent skeletal entity or as a particular symptom of a multitude of focal or systemic diseases of the hand skeleton. The diagnosis can usually be made synoptically together with the clinical and laboratory findings, the age of the patient, and radiographic

symptoms of the focus (marginal sclerosis, permeation, localization) and its surroundings (concomitant signs of osteoarthritis, arthritis and tumorous destruction). Further morphological differentiation occasionally requires the use of skeletal scintigraphy, CT, or MRI.

Table 43.1 Classification of cystic lesions on the hand skeleton

Pathogenesis and Clinical Symptoms

U

Cystic lesions in the skeleton of the hand have in common only demarcated loss of the bone structure. Their pathogenesis is extremely wide. They can appear either as independent skeletal entity or as a hallmark of an underlying disease. Various concomitant reactions, such as marginal osteosclerosis, bone expansion, periosteal reaction, and enthesopathic changes, may help to asses the nature of the cystic lesions and to identify the underlying disease. The cysts themselves usually cause no complaints and only become symptomatic when secondary phenomena or complications occur, e.g., bone-marrow edema or a pathologic fracture. Otherwise, symptoms in skeletal sections with cysts are determined by the primary disease.

U U

U

U

U

Bland bone cysts Cysts formed by osteonecroses/injuries Enthesiopathic bone cysts: – Ganglion cysts – Signal cysts with arthritic erosions – Subchondral cysts in osteoarthritis Cysts in inflammatory diseases of the skeleton: – Infectious cysts – Plasma cellular cysts – Cysts in rheumatic or seronegative arthritides Cysts in systematic diseases: – Acquired endocrine, metabolic, and granulomatous cysts – Inherited cysts in storage diseases – Inherited cysts in skeletal dysplasias Tumorous bone cysts: – Benign bone tumors – Malignant bone tumors

Classification Table 43.1 provides an attempted summary of the heterogeneous group of cystic lesions on the skeleton of the hand: there are overlaps.

Bone Cysts with No Pathological Relevance Vasa Nutricia “Vascular holes” represent vascular canals in the orthograde projection.

Posttraumatic Hemorrhagic Cysts There is a fine osteosclerotic margin around a focal osteolytic obliteration of the cancellous bone. The previous trauma often can no longer be recalled.

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Enthesopathic and Arthritic Diseases

Necrobiotic Pseudocysts, Idiopathic Carpal Cysts Local ischemic conditions are the pathogenesis of nonexpanding osteolyses of up to 3 mm with thin osteosclerotic margins. During reparative processes there occurs circumscribed bone-marrow fibrosis or – as a result of metaplasia of the surrounding pluripotent osteoblasts – the formation of cysts, which are lined with synoviumlike tissue.

Avascular Osteonecroses of the Carpus Cystic inclusions can be found in the lunate in ischemic lunate osteonecrosis (see Figs. 30.3, 30.7) and in both fragments in scaphoid nonunion (see Figs. 20.5, 20.6, 20.7). From stage II onward in both disease entities, there is formation of resorption cysts surrounded by a zone of osteosclerosis. These arise as a result of necrosis of the

bone marrow and the cancellous bone in the form of cystic defects. The cysts are located in the subchondral area of the lunate. In the scaphoid, they lie along the pseudarthrotic cleft in both scaphoid fragments. There is almost always a concomitant osteosclerosis of the cancellous bone.

Enthesopathic and Arthritic Diseases Bone cysts that appear in enthesopathic diseases are usually subchondral or subcortical. Subchondral cysts and intraosseous ganglion cysts cannot be differentiated histologically. Their walls consist of a cell layer resembling synovium, and the surrounding wall is osteosclerotic. Appropriate projections or slices display a direct neighborhood of the cystic cavity and the surface of the affected bone in both types of cysts, but the pathogenesis is fundamentally different: U A ganglion cyst (Figs. 43.3–43.6) is caused by mucoid degeneration of an inserting ligament with consecutive neogenesis of fibrovascular tissue. Its capillaries exude fluid from blood plasma. The fluid enters the surrounding bone space. This induces adjacent pluripotent bone cells to produce a synovium-like cell layer. The pathogenesis determines the intraosseous position of the cysts at the ligament insertions (Chapter 10). The articular cartilage always remains intact, and there are generally no signs of osteoarthritis. The cyst cannot be seen during arthroscopy despite being immediately adjacent to the bone surface along the

U

thickened tissue structures of the affected ligament, even when the bone structures are extremely thin (Fig. 43.3). Predisposed sites are the insertions of the scapholunate and lunotriquetral ligaments, the ulna head, and the capitate with it numerous ligamentary insertions. The density values of cysts in CT are between 10 and 30 HU. Subchondral cysts (Fig. 43.1) develop on the parts of joint surfaces that are exposed to a high mechanical load that abrades the articular cartilage. The cysts are in direct contact with the joint space and can be seen during arthroscopy. Contrary to earlier opinion, the cyst-surrounding synovial layer is not the articular synovium that has folded into the defect but has arisen secondarily as a desmoplastic transition of pluripotent bone cells caused by contact with joint fluid. Osseous reactions in the ulnocarpal impaction syndrome, as shown in Fig. 43.1 in addition to radiocarpal osteoarthritis, are similar. Radiographic signs of osteoarthritis include narrowing of the joint space, subchondral osteosclerosis, and osteophytic formations.

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Fig. 43.1 Subchondral cysts in osteoarthritis. Osteoarthritis in the radioscaphoid compartment and an ulnolunotriquetral impaction syndrome have developed on the base of longstanding scapholunate dissociation and positive ulnar variance. Signs of osteoarthritis include subchondral cysts in the ulna head and the lunate, triquetrum, and capitate.

a

b

Fig. 43.2 a, b Cystic lesions in rheumatoid arthritis. a So-called signal cysts with sharp contours and partially sclerotic margins can be seen in the heads of metacarpal I and the first proximal phalanx at an early stage of disease. b At an advanced stage of disease in a different patient, there are inflammatory cystic defects in the head of metacarpal II. There are mutilating lesions in the base of the proximal phalanx. (Courtesy of G. Lingg, MD, Bad Kreuznach.)

a

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Fig. 43.3 a–c Intraosseous ganglion cyst in the lunate originating from the scapholunate ligament. a Axial CT image demonstrates a cystic lesion with marginal sclerosis on the radial side of the lunate. There is a transcortical defect facing the scapholunate joint space. b Coronal MPR image clearly shows the location of the cystic lesion within the lunate and its connection to the scapholunate ligament. c Sagittal MPR image shows the size of the cystic lesion in relation to the diameter of the lunate.

Enthesopathic and Arthritic Diseases

Signal Cysts and Arthritic Erosions One of the early signs of arthritic joint disease is the signal cyst, which has either no, or only thin, marginal osteosclerosis (Fig. 43.2 a). At the beginning of the arthritic destruction process, erosions appear, initially in the bare areas where the articular bone is not covered by cartilage. They have no sclerotic margin and are accompanied by periarticular osteopenia and narrowing of the joint space. The other direct arthritic signs become manifest in the late stages. In the mutilation stage of rheumatoid arthritis, large cystic bone defects can develop adjacent to the affected joint (Fig. 43.2 b). Fig. 43.4 Large intraosseous ganglion cyst in the scaphoid. In the oblique-sagittal CT scan, the cystic lesion takes up a large portion of the internal structure of the scaphoid, which appears in danger of fracturing. There is a broad transcortical connection on the palmar side.

a

Fig. 43.5 a, b MRI of an intraosseous ganglion cyst in the lunate located at the insertion of the scapholunate ligament. a In the coronal T1 SE sequence, a ganglion cyst is visible in the typical location and with intermediate signal intensity, which is caused by imbedded tissue and fluid. b In the coronal T1 SE sequence with fat saturation after gadolinium application, the inside of the ganglion cyst appears hypointense, whereas the periphery and the ligament show moderate contrast enhancement. (Courtesy of R. Schmitt, MD, Bad Neustadt/ Saale.)

b

Fig. 43.6 a, b Intraosseous ganglion cyst in the lunate located at the insertion of the lunotriquetral ligament. a The axial CT scan shows a round, smoothly delineated lesion with peripheral osteosclerosis. b The coronal PD-weighted FSE sequence with fat saturation displays a hyperintense cystic lesion with a hypointense margin and a marked perifocal bone-marrow edema in the lunate. (Courtesy of R. Schmitt, MD, Bad Neustadt/ Saale.)

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Bone Cysts Induced by Infection Cystic bone lesions are observed in osteomyelitic and arthritic infections with mycobacteria or fungi (Fig. 41.4). Brodie abscess is a special form of an infectious cystic

process. It is located in the distal radius, is surrounded by a zone of osteosclerosis, and has a drainage canal directed toward the joint.

Bone Cysts in Systemic Diseases Metabolic Diseases That Are Associated with Deposits Deposits of metabolic products (monosodium urate monohydrate, amyloid, cholesterol) are surrounded by granulation tissue with many phagocytes. These cell aggregations induce osteolyses with reactive marginal sclerosis of varied and generally irregular thickness.

Gout The main diagnostic signs in radiography are the sharpedged, marginal erosion at the joint surface, the “punched-out” defect that undermines the subchondral bone, and the so-called gouty thorn as a spur-shaped bony prominence (Figs. 34.1–34.3). The tophic osteolyses are polymorphic and can be subdivided by trabeculae. When there is a spread in metaphyseal or diaphyseal direction, they assume an oval shape. The margins are osteosclerotic with a highly variable thickness within the same lesion. One part of the joint surface always remains intact. In the erosion and immediately adjacent to it, the urate salts cause soft-tissue thickening (gouty tophi). The diagnosis is confirmed by the patient’s history and laboratory findings.

Chondrocalcinosis (CPPD Deposition) Very large subchondral cysts can develop in chondrocalcinosis (pseudo gout, CPPD deposition), which is a predisposing factor for osteoarthritis. The radiographic appearance resembles that of subchondral cysts with prominent marginal osteosclerosis. The concomitant soft-tissue calcifications (Figs. 34.3–34.6) usually indicate the diagnosis.

and subchondral cysts in longstanding disease (Fig. 35.3). Periarticular osteopenia is usually prominent. Characteristically, amyloid deposits cause symmetric swelling of the soft tissues of the hand and carpal instability as a result of ligament erosions.

Hemochromatosis Siderophilia, an idiopathic iron-storage disease, mainly affects females. In the preclinical stage, it is manifested as typical deforming osteoarthritis with subchondral cysts, subchondral osteosclerosis, and symptomatic chondrocalcinosis of the articular cartilage. Indicative diagnostic criteria are the predisposed sites on the heads of metacarpals II and III with concomitant cysts surrounded by sclerotic margins and located far from the articular cartilage (Fig. 34.12). In contrast to osteoarthritis, the proximal and distal interphalangeal joints are not affected. CT reveals an increased density of between 85 and 100 HU for the liver parenchyma. The diagnosis is based on laboratory findings – the serum iron level is elevated with decreased iron-binding capacity and raised ferritin.

Xanthomatosis Osseous xanthomas are rare complications of hereditary hyperlipoproteinemia. The appearance is polymorphic in relation to size, configuration, and location. The size of the cysts varies from a few millimeters in disseminated disease to individual osteolyses that can lead to fracture. Their shape can be round or oval. There is usually a marginal osteosclerosis of variable density. Cancellous and cortical bone near the joints can be affected, as can the epiphyses or diaphyses. The diagnosis is based on laboratory results and is confirmed by the presence of further xanthomas, e.g. in the cutis or subcutis.

Amyloidosis Both the idiopathic and the secondary forms display sharply delineated erosions with osteosclerotic margins

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Bone Cysts in Systemic Diseases

Bone Cysts in Other Systemic Diseases “Brown Tumors” So-called brown tumors are manifested in primary and secondary forms of hyperparathyroidism. Radiographs reveal osteolyses in different locations and of different sizes (see Fig. 31.8). There are no characteristic signs on the margins. Depending on the tumor size and severity of the disease, the appearance can resemble a cyst with osteosclerotic margins, a cyst with central calcification, or an expansive bone tumor. Along with clinical symptoms and serological findings, the typical radiographic signs of tunneling and striation of the cortical layers and soft-tissue calcifications usually indicate the correct diagnosis.

Sarcoidosis (Osteitis Multiplex Cystices Jüngling) Noncaseating, epitheloid-cell granulomas result in round or polygonal, sharply demarcated “punched-out” defects up to 5 mm in diameter with osteosclerotic margins. The epimetaphyseal sections of the fingers are predisposed areas (Fig. 35.1). Further radiographic signs are diffuse osteoporosis, honeycombing structural changes, large defects with bone expansion, swelling of the surrounding soft tissues, and subperiosteal erosions.

Gaucher Disease This autosomal-recessive hereditary storage disease affects primarily Ashkenazi Jews. The skeletal lesions, which become radiographically manifest between the 20th and 40th years of life, are a result of displacement of the bone marrow by Gaucher storage cells. There is a irregular, coarse thinning of the cancellous and cortical bone and osteolytic, blistered lesions (Fig. 43.7), which can have portions of marginal osteosclerosis but usually display a fine rim. Finally, the bone expansion results in the typical Erlenmeyer-flask deformity of the tubular bones. There are additionally aseptic osteonecroses resulting from a focal disturbance in blood flow.

Fibrous Dysplasia (Jaffé–Lichtenstein Disease) This hamartomatous disease rarely affects the bones of the hand. It can appear either in isolation or as part of the

Fig. 43.7 Gaucher disease in a 16-year-old adolescent. Osteolytic lesions in the distal portions of the proximal and middle phalanges. Slight distension of the third middle phalanx in the shape of an Erlenmeyer flask. Only discrete coarsening of the cancellous bone in the other fingers. (Courtesy of K. Schneider, MD, Munich.)

McCune–Albright syndrome with the triad consisting of fibrous dysplasia, premature puberty, and café-au-lait spots (irregular “coast-of-Maine” margins) as a result of a postzygotic gene mutation. This developmental abnormality of the bone-building mesenchyme leads to fibroosseous metaplasia. The bone produced is immature with many blood vessels, a fibrotic stroma, and irregular, disconnected trabeculae. The normal bone marrow and the healthy bone are displaced. The radiographic morphology is usually a mixed lesion with structural parts that are cystic and osteosclerotic, and have a “frostedglass” appearance. The affected bone has thin cortical layers and is deformed and often enlarged (Fig. 43.8). In 30 % of cases, there is a polyostotic manifestation; in 90 % one side is more severely affected. In scintigrams, the foci show increased nuclid uptake. In MRI, the lesions in the medullary space are hypointense in T1-weighted sequences as a result of displacement of the fatty bone marrow by connective tissue. Its highly cellular, metabolically-active character is represented by signal intensity in the medullary space in the STIR sequence. The increased perfusion of the highly vascular, immature bone leads to a marked contrast enhancement. Embedded cysts with high signal intensity and low enhancement in all sequences correspond to circumscribed cell necroses with hemorrhages.

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a

b

c

d

Fig.43.8 a–d Fibrous dysplasia in McCune–Albright disease. Cystic inclusions of fibrotic tissue in the distal sections of the radius and the ulna. a The dorsopalmar radiograph reveals cystic lesions, incomplete septal divisions, and nonsclerotic margins. The cortical bone layer is thinned and interrupted in the radial styloid process. b Coronal CT with multiplanar reconstruction. c The PD-weighted FSE sequence with fat saturation shows defects that are hypointense in the center and hyperintense in the periphery. d The plain T1-weighted SE sequence shows intermediate signal intensity, indicating fibrotic tissue in the medullary space with hemorrhagic components. There is peripheral enhancement (not shown here). (Courtesy of R. Schmitt, MD, Bad Neustadt/Saale.)

Neurofibromatosis type I (Recklinghausen Disease) Polyostotic bone lesions as the result of neurogenic tumor formation are seen very rarely on the skeleton of the hand in Recklinghausen disease (Fig. 43.9). There are oval osteolyses with osteosclerotic margins and proliferative periosteal reactions. Neurofibromatosis must be differentiated from nonossifying fibroma that is found more often than would be expected by chance in Recklinghausen disease.

Tuberous Sclerosis (Pringle–Bourneville Disease) Cystic, radiolucent areas and sometimes periosteal calcifications are often also found in the hand skeleton in this rare, hereditary phacomatosis as an expression of neuroectodermal malformation.

Fig. 43.9 Neurofibromatosis of the hand skeleton. Oval osteolyses with partially osteosclerotic margins in the middle phalanx of the index finger and the proximal phalanx of the middle finger next to thickened soft tissues. (Courtesy of H. Rosenthal, MD, Hannover.)

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Therapeutic Options

Cystic Bone Tumors

Table 43.2 Bone tumors with a cystic aspect U U

Some benign and malignant bone tumors listed in Table 43.2 can have a partial or complete cystic appearance. These entities are discussed in Chapter 44.

U U U U U

Differential Diagnosis

U U U

Sometimes the pathognomonic radiographic signs alone can lead to the diagnosis. Because of the broad spectrum of such signs, it is generally necessary to include clinical and laboratory data when evaluating a radiograph. For further diagnostic differentiation, CT (e.g., to determine the density of an intraosseous lipoma or to visualize the transcortical canal of an intraosseous ganglion cyst), skeletal scintigraphy (increased nuclid uptake, e.g., in

Enchondroma, enchondromatosis Juvenile and aneurysmal bone cysts Nonossifying fibroma Hemangioendothelioma Intraosseous lipoma Glomus tumor Chondroblastoma Giant-cell tumor (osteoclastoma) Multiple myeloma (plasmacytoma) Osteolytic bone metastases

fibrous dysplasia and sarcoidosis of the bone), or MRI can be helpful. If there are cystic lesions in the hand skeleton with clinical or imaging suspicion of a malignant bone tumor, local staging should be carried out with CT and/or MRI, or even arteriography.

Therapeutic Options Treatment depends on the respective underlying disease. See the relevant chapters on carpal instability (Chapter 23), osteoarthritis (Chapter 27), osteonecroses of the hand skeleton (Chapter 30), osteopenic bone diseases (Chapter 31), osteopathies caused by hormones, vitamins, medications, or toxins (Chapter 33), crystal deposition osteoarthropathies (Chapter 34), rare osteoarthropathies (Chapter 35), rheumatoid arthritis (Chapter 36), seronegative spondylarthropathies (Chapter 37), osteomyelitis (Chapter 41), bone tumors (Chapter 44), soft-tissue tumors (Chapter 45), and disturbances of the arterial circulation (Chapter 48).

Further Reading Birkner R. Das typische Röntgenbild des Skeletts. Munich: Urban & Schwarzenberg; 1977:271–273. Belusa M. Intra-osseous epidermoid cyst. Handchir Mikrochir Plast Chir. 1991;23:200–201. Bennett DC, Hauck RM. Intraosseous ganglion of the lunate. Ann Plast Surg. 2002;48:439–442. Calcagnotto G, Sokolow C, Saffar P. Intraosseus synovial cysts of the lunate bone: Diagnostic problems. Chir Main. 2004;23:17–23. Dihlmann W. Gelenke, Wirbelverbindungen. 3rd ed. Stuttgart: Thieme; 1987:89–94. Fendel A, Horger MS. McCune-Albright syndrome. Fortschr Röntgenstr. 2003;175:135–136. Flynn JE. Hand Surgery. Baltimore: Williams & Wilkins; 1966. Förstner H. Intraosseous ganglion in the area of the wrist. Chirurg. 1992;63:977–979. Freyschmidt J. Skeletterkrankungen. Heidelberg: Springer; 1993:157 and 709.

Genant HK, Heck LL, Lanzl LH, Rossmann K, Van der Horst J, Paloyan E. Primary hyperparathyreoidism: A comprehensive study of clinical, biochemical and radiographic manifestations. Radiology. 1973; 109:513–524. Gielen JL, van Holsbeeck MT, Haugenstaine D et al. Growing bone cysts in long term hemodialysis. Skeletal Radiol. 1990;19:43–49. Greenspan A. Orthopedic Imaging - A Practical Approach. Philadelphia: Lippincott Williams & Williams; 2004. Gubler FM, Maas M, Dijkstra PF, de Jongh HR. Cystic rheumatoid arthritis: Description of a nonerosive form. Radiology. 1990;177: 829–834. Harbinson JB, Nice Jr CM. Familial pachydermoperiostosis presenting as an acromegaly-like syndrome. Am J Roentgenol. 1971;112: 532–536. Iwahara T, Hirayama T, Takemitu Y. Intraosseous ganglion of the lunate. Hand. 1983;15:273–298. Jaffe HL. Metabolic, Degenerative, and Inflammatory Diseases of Bones and Joints. Philadelphia: Lea & Febinger; 1972;80 and 760. Freyschmidt J, Brossmann J, Sternberg A, Wiens J. Koehler/Zimmer’s Borderlands of Normal and Early Pathological Findings in Skeletal Radiography. 5th ed. Stuttgart: Thieme; 2002. Luke DL, Pruitt DL, Gilula LA. Communicating intraosseous ganglion of the lunate. Can Assoc Radiol J. 1993;44:304–306. Magee Th, Rowedder AM, Degnan GG. Intraosseous ganglia of the wrist. Radiology. 1995;195:517–520. Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin. 2004;20:249–260. Niepel GA, Sit’a S. Enthesiopathy. Clin Rheum Dis. 1979;5:857–872. Pahlos JM, Valdes JC, Gavilan F. Bilateral lunate intraosseous ganglia. Skeletal Radiol. 1998;27:708–710. Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: Saunders; 2002. Schajowicz F, Sainz MC, Slullitel JA. Juxta-articular bone cysts (intraosseous ganglia). A clinicopathologic study of 88 cases. J Bone Joint Surg. 1979;61B:107–116.

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Bone Tumors H. Rosenthal, R. Schmitt, A. Staebler

Primary and secondary bone tumors in the hand are rare. The fact that the most common bone tumors of the hand have a relatively characteristic radiographic morphology facilitates differential diagnosis. However, the entire spectrum of bone tumors, including tumorlike lesions, can appear in the hand. Lesions in atypical locations, such as the carpal bones, often require a biopsy for diagnosis. Radiographs provide essential information for the classification of these

Pathoanatomy and Clinical Symptoms Tumors of the hand are mostly soft-tissue tumors. Bone tumors of the hand constitute only 2 % in overall statistics from centers for hand surgery. Data from bone-tumor centers show that of all bone tumors, only 4 % are located on the skeleton of the hand. One reason for this is the very early conversion of the bone marrow of the hand into fatty marrow. Primary tumors associated with hematopoietic marrow and metastases are generally located at or near the trunk. Other tumors and tumorlike lesions develop on skeletal parts with high longitudinal growth and metaphyseal remodeling, such as those around the knee joint.

tumors. MRI delivers important additional information in some tumorous entities. It is the method of choice to determine the extent of the tumor for planning therapy. CT imaging is useful in searching for the nidus of an osteoid osteoma and, to a certain extent, in osteosclerotic tumors. Skeletal scintigraphy is applied for the evaluation of osteoid osteomas, polyostotic neoplastic disease, and, in individual cases, differentiation from osteomyelitis.

The distribution of the benign/malignant nature of bone tumors of the hand is remarkable (Table 44.1). Centers for hand surgery report that 97 % of their patients’ tumors are benign. Even in the preselected patient population in these centers, the proportion of benign lesions among bone tumors of the hand is 90 %. Malignant bone tumors in the hand are thus extremely rare. A further peculiarity is that soft-tissue tumors in the hand lead to secondary skeletal changes earlier than in other parts of the body because of their close proximity to bones and the limited spaces in the hand in which they can expand.

Table 44.1 Incidence of bone tumors of the hand Incidence

Benign Tumors

Malignant Tumors

Tumorlike Lesions

Relatively frequent

Enchondroma

Rare

Osteoid osteoma Osteochondroma Osteoblastoma Giant-cell tumor Periosteal chondroma

Metastasis Multiple myeloma Chondrosarcoma

Aneurysmal bone cyst Reparative giant-cell granuloma Epidermal cyst Brown tumor

Extremely rare

Chondroblastoma Chondromyxoid fibroma Nonossifying fibroma Hemangioma Eosinophilic granuloma Adamantinoma

Osteosarcoma Ewing sarcoma Malignant fibrous histiocytoma Fibrosarcoma Angiosarcoma Hemangioendothelioma

Juvenile bone cyst Fibrous dysplasia Paget disease Hemophilic pseudotumor

Bone island Intraosseous ganglion

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Bone Tumors of Chondrogenous Origin

Diagnostic Imaging

Computed Tomography

Radiography

MRI has replaced CT in assessment of soft tissues for planning surgery. An important indication for CT imaging, however, is the clinical or scintigraphic suspicion of an osteoid osteoma. The multiplanar capability provided by spiral CT extends its spectrum of indications to periarticular cystic osteolyses and osteosclerosing tumors. Cortical destruction of the carpal bones can also be identified reliably.

Conventional radiographs of the hand are fundamental for assessment in all tumor cases. Documentation of osteoblastic and osteolytic bone changes destruction of cortical and cancellous bone serve as diagnostic criteria. Periosteal reaction and involvement of the paraosseous soft tissues provide information about the speed of growth and the nature of the tumor. Assessment of the tumor matrix often makes it possible to determine the tumor entity. A few tumorous lesions have multicentric manifestations on the hand.

Arteriography The diagnostic value of arteriography in the evaluation of bone tumors is very limited. Aside from rare exceptions, imaging of the vasculature is only indicated for surgical planning with large tumors.

Nuclear Medicine Skeletal scintigraphy has only secondary importance in the evaluation of bone tumors in the hand. Its most important contribution is identification of an osteoid osteoma, as the nidus can occasionally escape detection in survey radiographs. This is often the case particularly in the carpal area.

Magnetic Resonance Imaging The most important and comprehensive information about the osseous hand skeleton and surrounding soft tissues for surgical planning is provided by MRI. Multiplanar imaging with the use of surface coils when malignancy is suspected provides the most reliable information about the size of the tumor and its relation to surrounding soft tissues. It is important to obtain as much information as possible about tumor spread into the medullary space of bones. MRI is particularly useful for evaluation of enchondromas, which are the most common bone tumors in the hand, since these tumors display a characteristically high-signal intensity in T2-weighted sequences. Although small pathologic tumor vessels cannot be visualized, integration of MR angiography into the MRI sequence protocol allows determination of the tumor location in relation to blood vessels and the frequent vascular variants.

Tumor Entities

Bone Tumors of Chondrogenous Origin Enchondroma (Chondroma) Pathoanatomy and Clinical Symptoms Enchondromas are the most common bone tumor of the hand skeleton. They consist of mature cartilaginous cells, which presumably develop from displaced epiphyseal cartilage. For this reason, they are most often found in the distal parts of the metacarpals and in the proximal parts of the phalanges. They show little growth potential. An enchondroma is usually a coincidental finding or is detected with pathologic fractures (Fig. 44.1 a), generally

between the second and fifth decades of life. There is no sex predisposition. Aside from an occasional slight distension of the affected bone, it causes no complaints. In contrast to histologically similar lesions of the long tubular bones, enchondromas have only a very slight tendency to become malignant. This is not true for enchondromatosis, which is a special polyostotic form with possible malignant transformation in up to 30 % of cases. The purely polyostotic form (Ollier disease) is differentiated from Maffucci syndrome (Fig. 44.3), which is a combination of multiple enchondromas and soft-tissue hemangiomas.

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a

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Fig. 44.1 a, b Enchondroma of the proximal phalanx of the index finger. a There is an expansive osteolysis with endosteal cortical thinning. Sharp demarcation of the distal border, but not of the proximal. A pathologic fracture has occurred. b In the T2*-weighted GRE sequence, the enchondral tumor appears hyperintense and is well delineated.

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Fig. 44.2 a, b Enchondroma in the proximal phalanx of the middle finger. a There is an osteolytic lesion, which largely fills the medullary space, with endosteal thinning of the cortical bone. Fine osteosclerotic mottling within the tumor. b High-resolution CT imaging more clearly visualizes the endosteal erosion of the cortical bone and spotty tumor matrix calcifications.

Fig. 44.3 Maffucci syndrome. This image detail shows several enchondromas in the proximal phalanx with deforming growth disturbance and phleboliths in the soft tissues.

Magnetic Resonance Imaging

Diagnostic Imaging Radiography The radiographic appearance is characterized by a sharply contoured osteolysis with endosteal bone resorption in the phalanges and metacarpal bones (Figs. 44.1, 44.2). The carpal bones are almost never affected. A thin osteosclerotic margin and a moderate, blistery distension are common. Periosteal reactions are rarely seen and usually result from reparative healing processes following pathologic fractures. Identification of punctate calcifications within the cartilaginous matrix of the tumor, which resemble popcorn, are strongly pathognomonic for this tumor entity. A special form with the same tumor characteristics is the periosteal chondroma (Figs. 44.4, 44.5).

The cartilaginous tumor matrix has a characteristic lobulated appearance, expansive tumor growth, and high signal intensity in T2-weighted MRI sequences. Differentiation from a low-grade chondrosarcoma, which is difficult to perform in the long tubular bones, is of secondary importance in the skeleton of the hand.

Differential Diagnosis Solitary bone cysts, aneurysmal bone cysts, epidermoid cysts, giant-cell tumors, chondrosarcomas, and other rare bone tumors must also be considered.

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Bone Tumors of Chondrogenous Origin

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Fig. 44.4 a, b Proliferating chondroma in periosteal location. a Sagittal CT image with 0.5 mm slice thickness shows subtle thinning of the cortical bone on the dorsal side of the metacarpal head and spur-shaped periosteal calcification. b The core of the tumor appears hypointense in the contrastenhanced T1-weighted SE sequence with fat saturation. The periphery is hyperemic, especially proximally.

Fig. 44.5 Periosteal chondroma of the second metacarpal in a 12-year-old boy. Expansive tumor growth in the flame-shaped, spicula-like periosteum and fine calcifications in the tumor matrix. Scalloping of the third metacarpal by the tumorous lesion.

Magnetic Resonance Imaging

Osteochondroma (Cartilaginous Exostosis) Pathoanatomy and Clinical Symptoms Osteochondromas of the hand, which are benign lesions of cartilaginous origin, are considerably rarer than enchondromas and are also often detected only incidentally. Their development is associated with the epiphyseal plates, and they often appear as hereditary multiple exostoses in familial exostosis disease. Osteochondromas are frequently accompanied by growth disturbance.

Diagnostic Imaging Radiography The radiographic finding with cone-shaped or cauliflower-shaped protrusions is characteristic (Figs. 44.6, 44.7). A special carpal form is exostosis in Trevor disease (dysplasia epiphysealis hemimelica), which can also be manifested as an articular chondroma.

The nonossified cartilaginous caps on the exostoses can only be seen with MRI. The cartilaginous caps appear hyperintense in T1- and T2-weighted sequences (Fig. 44.8). Their malignant transformation into chondrosarcoma can be detected more reliably with MRI than with radiographic procedures.

Differential Diagnosis Carpal bossing (carpe bossu) (see Fig. 28.1), an exostotic protrusion on the back of the hand, is considered an os styloideum, and thus a normal variant and not a tumor. Chronic mechanical irritation can lead to exostotic protuberances on the short tubular bones of the hand as a result of new periosteal bone formation. Ossification of a periosteal hematoma on the diaphyses of the short tubular bones is considered responsible for Turret exostosis (Fig. 44.9). Subungual exostosis is also a reactive form of bone transformation.

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Fig. 44.6 Cartilaginous exostosis (osteochondroma) in the distal ulna of a 9-yearold boy. Cauliflower-shaped thickening of the distal ulna. Growth disturbance and a 2 cm-shortened ulna with bow-shaped deformity of the radial shaft.

Fig. 44.7 Hereditary multiple exostoses in an 11-yearold boy. Widening of the distal radius with three exostotic protrusions. Small cartilaginous exostoses in the ulnar metaphysis and metacarpals III and IV. Madelung deformity.

Chondroblastoma, Chondromyxoid Fibroma Both benign tumor entities are very rare and have only been observed on the hand in individual cases. The chondroblastoma differs from the enchondroma in its predisposed epimetaphyseal location. Marginal osteosclerosis and periosteal reactions are often seen in chondromyxoid fibromas.

Fig. 44.8 Cartilaginous exostosis (osteochondroma) on the distal ulna metaphysis of an 8-year-old girl. The tip of the exostosis displays a hyperintense cartilaginous cap in the sagittal T2-weighted FSE sequence.

Fig. 44.9 Turret exostosis on the proximal phalanx. Plateau-shaped periosteal thickening on the dorsal side of the diaphysis of a 34-yearold manual worker.

Chondrosarcoma Pathoanatomy and Clinical Symptoms Chondrosarcomas are by far the most common of the extremely rare primary bone malignancies of the hand. The proportion of secondary chondrosarcomas is about 2 0 %. These usually develop from Ollier disease or Maffucci syndrome. Males are somewhat more often affected, but there is no predisposed age.

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Bone Tumors Originating from Osseous Tissue

Diagnostic Imaging Radiography The sites most often affected are the metacarpals and the proximal phalanges. In comparison to enchondromas, chondrosarcomas cause destruction of the cortical bone and formation of extraosseous soft tissue. Enchondral calcifications facilitate the classification of this tumor (Fig. 44.10).

Computed Tomography The expansive osteolytic lesions caused by chondrosarcomas lead to early focal destruction of the periosteum on the hand skeleton, which is best visualized with CT. The sensitivity in confirming endotumorous calcifications is higher in CT than in radiography. a

Magnetic Resonance Imaging The cartilaginous tumor matrix has a characteristic appearance in MRI similar to that of enchondromas, with marked high-signal intensity in T2-weighted sequences. The criteria of malignancy, i.e., penetration of the cortical bone and extraosseous tumor spread, also indicate the tumor entity. Dynamic MRI displays a more rapid contrast enhancement behavior than is seen in enchondromas.

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Fig. 44.10 a, b Chondrosarcoma of the distal phalanx of the thumb. a Large eccentric osteolytic lesion within the tumorous distension of the distal phalanx. Septal internal structures. b The coronal CT image with a slice thickness of 0.5 mm shows advanced destruction of the cortical bone on the radial side and large paraosteal tumor spread.

Bone Tumors Originating from Osseous Tissue Osteoid Osteoma Pathoanatomy and Clinical Symptoms The osteoid osteoma is a benign bone-forming lesion with a nidus originating from osteoid trabeculae. The highest incidence occurs in the second decade of life with male predominance. Nocturnal pain, which subsides with salicylates, is characteristic. Clinically it can resemble monarthritis. Osteoid osteomas are rare, but not as rare on the hand as on the rest of the body, and are of special importance because of their clinical symptoms and difficulty in detection.

osteosclerosis, is typically found in the cortical layer of the long tubular bones (Figs. 44.11 a, 44.12 a). If the tumor is located in the cancellous bone, reactive osteosclerosis can be absent. If the nidus has no central calcification, it can easily be overlooked in radiographs of the hand, especially in the carpal region.

Computed Tomography The nidus can usually be identified in CT imaging. Thin slices are necessary without reconstruction gaps. Spiral CT in a high-resolution bone kernel with MPR postprocessing (Fig. 44.12 a) is especially well suited.

Magnetic Resonance Imaging

Diagnostic Imaging Radiography A central osteolysis, generally measuring only a few millimeters in diameter and accompanied by strong reactive

Osteoid osteomas located in the cancellous bone of the carpus often cause considerable bone-marrow edema and occasionally concomitant synovitis. These findings, which are clearly evident in T2-weighted sequences, can

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occasionally mask the actual nidus. Therefore, it is important to obtain thin slices. After administration of gadolinium, the noncalcified nidus reveals intense contrast enhancement (Figs. 44.11 b–d, 44.12 b).

Nuclear Medicine If an osteoid osteoma is clinically suspected, confirmation or exclusion can also be achieved with skeletal scintigraphy, as the well-vascularized nidus shows a characteristically intense nuclide uptake.

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Fig. 44.11a–d Osteoid osteoma in the subcapital shaft of the proximal phalanx of the index finger in a 26-year-old woman with pain that is relieved by aspirin. a The dorsopalmar radiograph shows a longitudinal, sharply contoured area of an osteolytic lesion in the distal shaft of the proximal phalanx. The nidus has as a dense spot within the osteolysis. The surroundings display distinct osteosclerosis. b In the fat-saturated PDweighted FSE sequence, the osteolysis is hyperintense with a hypointense nidus and cancellous osteosclerosis. c An area of decreased signal intensity is seen in the T1weighted SE sequence. The osteolysis has intermediate signal intensity. d After administration of gadolinium, the osteolysis shows strong contrast enhancement. The nidus remains hypointense.

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Fig. 44.12 a, b A 54-year-old man with an osteoid osteoma in the hamate. a Axial CT image shows a heterodense tumor in the body of b Intense contrast enhancement in the tumor displayed in a fat-saturated T1-weighted SE sequence. The calcified nidus the hamate. The nidus in the center of the tumor is calcified, remains hypointense. and the surroundings show osteolytic destruction.

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Bone Tumors Originating from Connective Tissue

Osteoblastoma The rare osteoblastoma is a benign bone-building tumor with a large diameter compared to that of an osteoid osteoma, but with a similar histologic structure. The osteodestructive lesion mostly measures over 1.5 cm in diameter. Early formation of a soft-tissue component has been observed on the hand skeleton. This tumor, like the osteoid osteoma, is well vascularized.

have been described in the literature under the terminology pseudomalignant osseous tumor of the soft tissues, fibro-osseous pseudotumor of the finger, and bizarre paraosseous osteochondromatous proliferation (Nora’s lesion).

Diagnostic Imaging Radiography Osteosarcomas are most often found in the metacarpals and proximal phalanges. Tumorous osteoid, cortical destruction, and involvement of the soft tissues may be indicative diagnostic criteria.

Osteosarcoma Pathoanatomy and Clinical Symptoms An osteosarcoma is a malignant mesenchymal tumor with osteoid formation. This most common malignant primary bone tumor is extremely rare in the hand. Fewer than 40 cases have been documented worldwide, at least four of which were induced by radiation. Because this tumor is so rare, even histologic results should be reviewed critically, as benign lesions with radiographic and histologic similarities to osteosarcomas must be considered in differential diagnosis. This is especially true of reactive florid periostitis. Similar lesions in the hands that can be confused with osteosarcomas

Computed Tomography and Magnetic Resonance Imaging If radiographs raise suspicion of an osteosarcoma, contrast-enhanced MRI provides the most useful information to determine the degree of extraosseous tumor expansion. One should especially look for “skip lesions” within the tubular bones at a distance from the main tumor location.

Bone Tumors Originating from Connective Tissue Nonossifying Fibroma, Desmoplastic Fibroma The nonossifying fibroma is often found in an eccentric position in the long tubular bones and has osteosclerotic margins. This is a “leave-me-alone” lesion induced by a local growth disturbance. The nonossifying fibroma is very seldom seen in the hand. This rare desmoplastic intraosseous fibroma with a characteristic coarse internal structure originates from connective tissue and can affect the distal radius section.

Giant-cell Tumor (Osteoclastoma)

aneurysmal bone cysts, the giant-cell tumor rarely appears before the epiphyseal plates have closed. The highest incidence occurs during the third decade of life, with a slight predominance among males.

Diagnostic Imaging Radiography The characteristic location is in the epimetaphyses. The eccentric osteolysis displays no calcification of the matrix, but occasionally pseudotrabeculation (Fig. 44.13 a). Its blistery distension and cortical destruction can resemble aneurysmal bone cysts.

Computed Tomography

Pathoanatomy and Clinical Symptoms Giant-cell tumors affect the skeleton of the hand in 3 % of cases. A further 6 % of these tumors are found in the epiphysis of the distal radius section. In contrast to

The expansive osteolysis usually leaves a very thin bony shell, which can best be seen in CT imaging. The lack of matrix calcification is indicative of the disease entity.

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Magnetic Resonance Imaging The giant-cell tumor has a high recurrence rate and tends to recur by implantation after surgical excision and biopsy. MRI is essential for optimal planning of the obligatory surgical therapy. The tumor is normally located periarticular and displays strong contrast enhancement. During surgery, the tumor cavity is filled with bone cement after tumor resection. MRI is also the procedure of choice for detection of tumor recurrences.

Malignant Fibrous Histiocytoma (MFH), Fibrosarcoma When originating from the bones of the hand, these tumor entities are extremely rare and have been reported in only a few case studies. These tumors more often originate in soft tissues and lead secondarily to osseous destruction (Fig. 44.14).

Bone Tumors Originating from the Endothelium Hemangioma

Magnetic Resonance Imaging

Pathoanatomy and Clinical Symptoms Only 2 % of skeletal hemangiomas are found in the hand. On the forearm and hand, they are often associated with hemangiomas of the more superficial soft tissues (Fig. 44.15).

Diagnostic Imaging Radiography Hemangiomas of the bones can be recognized by their fine, honeycombed structural remodeling of the bone (Fig. 44.15 a). Sarcoidosis is a possible differential diagnosis, but has coarser trabeculae.

Computed Tomography CT can provide useful information in the differential diagnosis of osteolyses within the cancellous bone. Hemangiomas of the bone, especially when the surrounding soft tissues are involved, lead to longitudinal destruction of the cortical bone with osteosclerotic margins. The cause is penetrating the hypertrophic nutritial vessels (Fig. 44.15 b, c).

Direct visualization of the blood vessels is possible with MRI (Fig. 44.15 d). MR angiography should be combined with the obligatory administration of gadolinium. There are usually no pathologic vessels in isolated skeletal hemangiomas.

Arteriography Angiography is not indicated for isolated skeletal hemangiomas. It is performed only in combination with phlebography for symptomatic hemangiomas and arteriovenous malformations with soft-tissue involvement for planning therapy. An osseous hemangioma does not constitute a contraindication for sclerosing therapy.

Hemangioendothelioma, Angiosarcoma This very rare malignant tumor, in contrast to other primary bone tumors of the hand, has a variable pattern of distribution with a predilection for the carpal and metacarpal bones. It can also display multifocal manifestation of the hand skeleton with osteolytic destruction. Multiple myeloma and metastases should be considered in differential diagnosis.

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Bone Tumors Originating from the Endothelium

Fig. 44.14 Malignant fibrous histiocytoma (MFH) in the diametaphyseal section of the radius in an 8-year-old boy. Inhomogeneous, cloudy osteosclerosis of the distal half of the radius shaft extending directly up to the epiphyseal growth plate. The periosteum is elevated and thickened in a circumscribed area. The proximal extension of the tumor cannot be determined.

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Fig. 44.13 a, b Giant-cell tumor of the radius. a A 3.5 cm osteolysis characteristically located in the epimetaphyseal section of the radius. Foggy pseudotrabeculation within the tumor. Erosions and thinning of the cortical bone. Indistinct tumor borders both proximally and distally. b The exact tumor extension is demonstrated in the T2*-weighted GRE sequence. The tumor matrix is mainly hyperintense in signal. The surrounding soft tissues are also hyperintense as a result of an inflammatory, hyperemic reaction.

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Fig. 44.15 a–d Osteoclastic hemangioma of the radius. a Several osteolytic structural defects with marginal osteosclerosis in the diametaphyseal transition of the radius. b Sagittal MPR display of a high-resolution CT dataset shows osseous lesions located primarily on the palmar side of the radius with some osteosclerotic margins.

c Axial CT source image reveals defects with osteosclerotic margins and destruction of the radial sigmoid notch. d After administration of gadolinium, the T1-weighted SE sequence with fat saturation shows strong contrast enhancement within parosteal angiomatous lacunae.

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Bone Tumors Originating from the Bone Marrow Ewing Sarcoma Manifestation of a Ewing sarcoma on the hand skeleton is extremely rare. The characteristic radiographic signs of a permeative osteolytic lesion associated with periosteal reaction are the same as in other locations. Osteomyelitis is the primary differential diagnosis.

Magnetic Resonance Imaging Local treatment of Ewing sarcoma of the hand is only performed after chemotherapy has been administered, just as in other locations. MRI is obligatory for initial tumor staging and follow-up of therapeutic response. In contrast to osteosarcoma, skip lesions are rarely observed in Ewing sarcoma.

a

Multiple Myeloma (Plasmacytoma), Malignant Lymphoma, Hodgkin Disease, and Leukemia Despite earlier reports in the literature of peripheral forms of multiple myeloma, diffuse involvement of the bones in the hand (Fig. 44.16 a) must be considered rare. In our own long-standing experience, the hand has only been involved in advanced stages of disease. There are only individual reports of solitary plasmacytoma (Fig. 44.16 b), as well as manifestations of malignant lymphoma and Hodgkin disease, on the hand. Osteolytic destruction in acute leukemia is rarely observed in childhood (Fig. 44.17). In adults, bone destruction near the trunk is seen only in far-advanced stages of disease.

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Fig. 44.16 a, b Different manifestations of multiple myeloma in the hand. a Diffuse osteolytic infiltration of the hand skeleton with sharply-contoured osteolyses. b Solitary infiltration of the fourth metacarpal. The shaft shows blistery distension, and the cortical bone is eroded and thinned. (Courtesy of U. Lanz, MD, Munich.)

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Fig. 44.17 Acute childhood leukemia in a 2-year-old girl. Diffuse soft-tissue swelling and multiple osteolyses in the metacarpals III–V with periosteal reaction.

Tumorlike Bone Lesions of the Hand

Tumorlike Bone Lesions of the Hand Enostoma, Bone Island

plays similar osteosclerotic zones in individual cases, but this can be differentiated by the clinical symptoms.

Pathoanatomy and Clinical Symptoms These entities are not actually tumors. The common lesions in the hand skeleton cause no clinical symptoms and are of no clinical importance. Acral osteoscleroses of the distal phalanges, which are often observed in inflammatory joint diseases, have a similar presentation.

Radiography Solitary or even multiple, small, round osteosclerotic zones in the cancellous bone with diameters of 2–10 mm without alteration of the surrounding osseous structures (Fig. 44.18) are observed. Only an osteoid osteoma dis-

Aneurysmal Bone Cyst Pathoanatomy and Clinical Symptoms Aneurysmal bone cysts are among the most common (5 %) tumorlike lesions of the hand. Seventy-five percent of patients are under the age of 20 years. There is no sex predilection.

Diagnostic Imaging Radiography These often rapidly growing lesions with indistinct contours cause a blistery distension with destruction of the cortical bone and formation of pseudotrabeculae (Fig. 44.19). The metacarpals as well as the proximal and middle phalanges are most often affected. As differential diagnoses, reparative giant-cell granuloma and tuberculous osteomyelitis should be considered.

Fig. 44.18 Enostoma (bone island) in the radial styloid process. The coronal MPR image of a CT dataset shows a thick osteosclerotic focus within the subchondral cancellous bone. No signs of destruction.

Fig. 44.19 Aneurysmal bone cyst in the fifth metacarpal of a 6-year-old girl. Blistery distension of the entire diaphyseal shaft with thinning of the cortical bone and band-shaped pseudotrabeculae. (Courtesy of D. Jiménez, MD, Madrid.)

Magnetic Resonance Imaging The characteristic sedimentation phenomena with a fluid level can often be observed in aneurysmal bone cysts (Fig. 44.20). Only the wall of the cystic lesion shows minimal contrast enhancement.

Fig. 44.20 Aneurysmal bone cyst in the ulna head. In the T2*-weighted GRE sequence, there is a fluid-sediment level within the hyperintense cyst resulting from corpuscular sedimentation of the cystic contents. The radius is subluxated in dorsal direction.

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Solitary Bone Cyst (Juvenile Bone Cyst) This most common tumorlike lesion in the long tubular bones has smooth margins and no tumor matrix. It often leads to thinning of the cortical bone and pathologic fractures with the characteristic radiographic appearance of a centrally displaced cortical fragment, the so-called fallen-fragment sign. Fewer than 1 % of bone cysts are manifested on the hand. The most important differential diagnosis is the enchondroma.

Reparative Giant-cell Granuloma This rare, nonneoplastic lesion is defined as an individual entity in the recent WHO classification of bone tumors. It is sometimes also found on the hand skeleton. Occurring slightly more often in males, this lesion usually appears between the second and fifth decades of life. It leads to blistery distension of the metacarpals or phalanges with thinning of the cortical bone, but not to reactive osteosclerosis. The radiographic morphology resembles that of an aneurysmal bone cyst, giant-cell tumor, or a “brown tumor”.

The origin of cystic and osteolytic lesions in the carpal region is almost always associated with a pathologic process in the adjacent joint. Besides an arthritic cyst (see Fig. 43.2), one must consider an intraosseous ganglion cyst, which causes a cystic osteolysis with osteosclerotic margins. The joint space is unremarkable (see Figs. 43.3–43.6). These most often occur on the radial side of the lunate (Fig. 44.21); the special biomechanics of the scapholunate compartment are thought to play the key role in its etiology. Similar lesions can be caused by intraosseous deposits of amyloid in chronic hemodialysis (see Fig. 35.3). Pigmented villonodular synovitis primarily affects the tendon sheaths of the hand, but bony erosions can result additionally.

Diagnostic Imaging Computed Tomography CT imaging can provide useful information for the differential diagnosis of osteolytic lesions in periarticular location. Intraosseous ganglion cysts are generally characterized in a cross-sectional image by a delineated, transcortical communication defect that is connected to the joint cavity (Fig. 44.21 a).

Magnetic Resonance Imaging

Miscellaneous Joint Diseases and Intraosseous Ganglion Cyst The close proximity of the skeletal elements to the numerous joints in the hand requires particular attention to diseases affecting the joints in the differential diagnosis of bone tumors.

Intraosseous ganglion cysts appear hyperintense in T2weighted sequences and display only marginal contrast enhancement after administration of gadolinium (Fig. 44.21 b). In pigmented villonodular synovitis, deposits of hemosiderin cause typical spots of decreased signal intensity in T2-weighted sequences.

Fig. 44.21 a, b Intraosseous ganglion cyst in the lunate.

a Axial CT scan with an eccentric, osteolytic lesion in the dorsoradial part of the lunate. The interruption in the cortical bone indicates that the ganglion cyst originates from the dorsal segment of the scapholunate (SL) ligament.

b The ganglion’s origin from the SL ligament is confirmed with contrast-enhanced MRI. The fat-saturated T1-weighted SE image shows marginal enhancement of the ganglion cyst, including the ligament. A coincidental finding is a hyperintense lesion in the capitate.

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Soft-tissue Tumors with Osseous Infiltration

Intraosseous Epidermal Cyst Traumatic displacement of epidermal cells with subsequent proliferation can lead to round or oval osteolytic lesions, especially on the distal phalanges. The secondarily altered bone can focally be scalloped with smooth osteosclerotic margins. There is no calcified matrix, as is seen in enchondromas. A glomus tumor with bone erosion causes clinically more severe complaints with a similar radiographic appearance. Other rare soft-tissue tumors, such as keratoacanthomas, can destroy the distal phalanx if they are located subungually. Radiographically, this must be differentiated from local osteomyelitis.

“Brown Tumor” in Hyperparathyroidism Smoothly contoured, expansive osteolyses (“brown tumors”) can develop in every form of hyperparathyroidism (see Fig. 31.8 a). The skeleton of the hand is occasionally affected. The development of osteolytic lesions can precede the characteristic appearance seen in hyperparathyroidism with subperiosteal resorption. Recalcification sets in after resection of the parathyroid epithelial bodies.

Other Bone Tumors A few case histories record manifestations on the hand for almost all tumor entities. The same applies to the

Fig. 44.22 Paget disease of the second metacarpal. Coarse cancellous bone structure and thinned cortical layers within the sausage-shaped, deformed metacarpal bone.

eosinophilic granuloma, the adamantinoma, fibrous dysplasia (see Fig. 43.8), and Paget disease (Fig. 44.22). Neurogenous tumors arising in the bones are extremely rare. Polyostotic bone lesions of the hand can, however, be found in neurofibromatosis (see Fig. 43.9). Proliferative periosteal reactions and oval osteolyses are restricted to individual fingers. Polyostotic small osteolyses with concomitant osteoscleroses can appear in tuberous sclerosis.

Bone Metastases Bone metastases rarely appear on the hand. According to the literature, their incidence lies between 0.007 % and 0.3 %. Phalangeal metastases are usually solitary and constitute the first manifestations of the malignant disease in 16 % of cases. The most common primary tumors are bronchial, renal, and breast carcinomas. The patients have usually passed their fifth decade of life. Although

the carpal bones and distal phalanges usually do not have primary bone tumors, with the exception of hemangioendotheliomas, skeletal metastases can invade all parts of the hand skeleton with a slight predilection for the distal phalanges. These are mostly osteolytic metastases (Fig. 44.23).

Soft-tissue Tumors with Osseous Infiltration Soft-tissue tumors, including sarcomas, very rarely infiltrate the adjacent bone. Exceptions are the anatomic regions of the skull, hand, and foot. The limited ability of the soft tissues to expand in these regions promotes infiltration of the bone by malignant skin tumors and softtissue tumors. Cross-sectional imaging is indicated in

ulcerated squamous-cell carcinomas and basalomas, just as in every soft-tissue sarcoma on the hand, to confirm or exclude involvement of the osseous hand skeleton (Fig. 44.24). Clinical indications for complementary CT and MRI should be generous in such cases.

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Therapeutic Options Benign bone tumors that are detected incidentally and cause no complaints generally need no treatment. If benign bone tumors, such as enchondromas or juvenile or aneurysmal bone cysts, cause endosteal erosion that could potentially lead to a fracture, or if a pathologic fracture has already occurred, the bone lesion is surgically resected, and the tumor cavity is filled with cancellous bone material obtained from the iliac crest. Surgical therapy is the same for an osteoid osteoma and a giant-cell tumor; the latter should be resected as generously as

possible in view of its high recurrence rate. Diagnostic imaging plays an important role in planning surgery of bone tumors on the hand skeleton. If a cartilaginous exostosis leads to growth disturbance and later to impairment of function, a corrective osteotomy is indicated. The rare malignant bone tumors are treated either by extense local resection or by amputation with subsequent surgery to restore the function of the hand. The indication for complementary or presurgical chemotherapy depends on the stage and grade of the bone malignoma.

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Fig. 44.24 Osseous infiltration of a squamous-cell carcinoma. Clinical aspect of an extensive squamous-cell carcinoma on the back of the hand with infiltration and osseous destruction of the second metacarpal from dorsal.

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Fig. 44.23 a–c Different manifestations of bone metastases in the hand skeleton. a Osteolytic metastasis of a colorectal carcinoma in the proximal phalanx with permeative bone destruction and tumorous, thickened soft tissues. b Osteolytic metastasis of a hypernephroma in the distal phalanx with subtotal bone destruction. c Osteoblastic metastasis of a thyroid carcinoma in the scaphotrapeziotrapezoid region. After therapy with radioactive iodine, further increase of the preexisting tumorous osteosclerosis.

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Therapeutic Options

Further Reading Antonijevic N, Radosevic-Radojkovic N, Colovic M, Jovanovic V, Rolovic Z. Multifocal plasmocytoma of hand and foot bones. Leuk Lymphoma. 1996;21:505–507. Arazi M, Memik R, Yel M, Ogun TC. Osteoid osteoma of the carpal bones. Arch Orthop Trauma Surg. 2001;121:119–120. Assoun J, Richardi G, Railhac JJ et al. Osteoid osteoma. MR imaging vs. CT. Radiology. 1994;191:217–223. Baraga JJ, Amrami KK, Swee RG, Wold L, Unni KK. Radiographic features of Ewing’s sarcoma of the bones of the hands and feet. Skeletal Radiol. 2001;30:121–126. Belusa M. Intra-osseous epidermoid cyst. Handchir Mikrochir Plast Chir. 1991;23:200–201. Besser E, Roessner A, Brug E, Erlemann R, Timm C, Grundmann E. Bone tumours of the hand. A review of 300 cases documented in the Westphalian Bone Tumour Register. Arch Orthop Trauma Surg. 1987;106:241–247. Bovee JV, van der Heul RO, Taminiau AH, Hogendoorn PC. Chondrosarcoma of the phalanx: a locally aggressive lesion with minimal metastatic potential: A report of 35 cases and a review of the literature. Cancer. 1999;86:1724–1732. Campanacci M. Bone and Soft Tissue Tumours. Heidelberg: Springer; 1999. Cawte TG, Steiner GC, Beltran J, Dorfman HD. Chondrosarcoma of the short tubular bones of the hands and feet. Skeletal Radiol. 1998; 27:625–632. Dahlin DC. Giant-cell bearing lesions of bone of the hands. Hand Clinics. 1987;3:291–297. Dahlin DC, Salvador AH. Chondrosarcomas of bones of the hands and feet. A study of 30 cases. Cancer. 1974;34:755–760. Daniel JN, Eglseder WA, Sydney SV. Giant cell tumour of the middle phalanx. Orthopedics. 2000;23:1097–1099. Davila JA, Amrami KK, Sundaram M, Adkins MC, Unni KK. Chondroblastoma of the hands and feet. Skeletal Radiol. 2004;33: 582–587. Dupree WB, Enzinger FM. Fibro-osseous pseudotumour of the digits. Cancer. 1986;58:2103–2109. Escobedo EM, Bjorkengren AG, Moore SG. Ewing’s sarcoma of the hand. Am J Roentgenol. 1992;159:101–102. Feldman F. Primary bone tumours of the hand and carpus. Hand Clinics. 1987;3:269–289. Freyschmidt J, Ostertag H. Knochentumoren: Klinik, Radiologie, Pathologie. Heidelberg: Springer; 1988. Friedman AC, Orcutt J, Madewell JE. Paget’s disease of the hand: Radiographic spectrum. Am J Roentgenol. 1982;138:691–693. Garcia J, Bianchi S. Diagnostic imaging of tumours of the hand and wrist. Eur Radiol. 2001;11:1470–1482. Glicenstein J, Ohana J, Leclercq C. Tumours of the Hand. Heidelberg: Springer; 1988. Greenspan A. Benign bone forming lesions: Osteoma, osteoid osteoma, osteoblastoma. Skeletal Radiol. 1993;22:485–500. Hayden RJ, Sullivan LG, Jebson PJ. The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin. 2004;20:335–343. Healey JH, Turnbull ADM, Miedema B, Lane JM. Acrometastases. J Bone Joint Surg. 1986;68A:743–746. Helms CA. Osteoid osteoma: The double density sign. Clin Orthop. 1987;222:167–173. Hudson TM. Fluid-fluid levels in aneurysmal bone cysts. A CT feature. Am J Roentgenol. 1984;141:1001–1004. James SL, Davies AM. Giant-cell tumours of bone of the hand and wrist: A review of imaging findings and differential diagnoses. Eur Radiol. 2005;15:1855–1866. James SL, Davies AM. Surface lesions of the bones of the hand. Eur Radiol. 2006;16:108–123.

Kalb K, Schlor U, Meier M, Schmitt R, Lanz U. Osteoid osteoma of the hand and wrist. Handchir Mikrochir Plast Chir. 2004;36:405–410. Kerin R. The hand in metastatic disease. J Hand Surg. 1987;12A:77–83. Klan MH, Shankman S. Osteoid osteoma: Radiologic and pathologic correlation. Skeletal Radiol. 1992;21:23–31. Kransdorf MJ, Stull MA, Gilkey FW, Moser RP Jr. Osteoid osteoma. Radiographics. 1991;11:671–696. Kransdorf MJ, Murphey MD. MR imaging of musculoskeletal tumours of the hand and wrist. Magn Reson Imaging Clin N Am. 1995;3: 327–344. Libson E, Bloom RA, Husband JE, Stoker DJ. Metastatic tumours of bones of the hand and foot. Skeletal Radiol. 1987;16:387–392. Liu J, Hudkin PG, Swee RG, Unni KK. Bone sarcomas associated with Ollier´s disease. Cancer. 1987;59:1376–1385. Mankin HJ. Chondrosarcomas of digits: Are they really malignant? Cancer. 1999;86:1635–1637. Montero LM, Ikuta Y, Ishida O, Fujimoto Y, Nakamasu M. Enchondroma in the hand retrospective study-recurrence cases. Hand Surg. 2002;7:7–10. Murphey MD, Flemming DJ, Boyea SR, Bojescul JA, Sweet DE, Temple HT. Enchondroma versus chondrosarcoma in the appendicular skeleton: Differentiating features. Radiographics. 1998;18: 1213–1237. Murray P, Berger R, Inwards C. Primary neoplasms of the carpal bones. J Hand Surg. 1997;24A:91–98. Nahra ME, Bucchieri JS. Ganglion cysts and other tumor related conditions of the hand and wrist. Hand Clin. 2004;20:249–260. O’Connor MI, Bancroft LW. Benign and malignant cartilage tumors of the hand. Hand Clin. 2004;20:317–323. Ogose A, Unni KK, Swee RG, May GK, Rowland CM, Sim FH. Chondrosarcoma of small bones of the hands and feet. Cancer. 1997;80:50–59. Palmieri TJ. Vascular tumours of the hand and forearm. Hand Clinics. 1987;3:225–240. Peh WC, Shek TW, Ip WY. Metadiaphyseal chondroblastoma of the thumb. Skeletal Radiol. 2000;29:176–180. Reinus WR, Gilula LA, Shirley SK, Askin FB, Siegal GP. Radiographic appearance of Ewing sarcoma of the hand and feet: Report from the Intergroup Ewing sarcoma study. Am J Roentgenol. 1985;144: 331–336. Schajowicz F, Sainz MC, Slullitel JA. Juxta-articular bone cysts (intraosseous ganglia). A clinicopathologic study of 88 cases. J Bone Joint Surg. 1979;61B:107–116. Schajowicz F. Histological Typing of Bone Tumours. Heidelberg: Springer; 1993. Sundaram M, Wang L, Rotman M, Howard R, Saboeiro AP. Florid reactive periostitis and bizarre parosteal osteochondromatous proliferation: Pre-biopsy imaging evolution, treatment and outcome. Skeletal Radiol. 2001;30:192–198. Takigawa K. Chondroma of the bones of the hand. A review of 110 cases. J Bone Joint Surg. 1971;53A:1591–1600. Torreggiani WC, Munk PL, Al-Ismail K et al. MR imaging features of bizarre parosteal osteochondromatous proliferation of bone (Nora’s lesion). Eur J Radiol. 2001;40:224–231. Torreggiani WC, Munk PL, Al-Ismail K et al. MR imaging of periosteal chondroma. J Comput Assist Tomogr. 1991;15:1008–1010. Varma DG, Kumar R, Carrasco CH, Guo SQ, Richli WR. Aneurysmal bone cyst. A clinicopathologic study of 238 cases. Cancer. 1992;69: 2921–2931. Vora RA, Mintz DN, Athanasian EA. Intraosseous schwannoma of the metacarpal. Skeletal Radiol. 2000;29:224–226. Wissinger HA, McClain EJ, Boyes JH. Turret exostosis. Ossifying hematoma of the phalanges. J Bone Joint Surg. 1966;48A:105–110. Wood VE. Hemangioma with bone lesions. J Hand Surg. 1982;7A: 287–290.

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Soft-tissue Tumors R. Schmitt

On the hand, soft-tissue tumors are more common than bone tumors. If the results of clinical examination remain equivocal, the localization and size of the tumor can be precisely determined with imaging methods. High-resolution ultrasonography (US) allows identification of the commonly occurring ganglion cysts, as well as their sites of origin. For all tumors of the hand, contrast-enhanced MRI is the method of choice for further investigation. It provides

Pathoanatomy and Clinical Symptoms

exact information regarding the localization and type of tissue of the tumor. Specific patterns are seen in ganglion cysts, epidermal inclusion cysts, lipomas, hemangiomas, giant-cell tumors of the tendon sheaths, glomus tumors, and tumors of the nerve sheaths. When a malignant soft-tissue tumor is suspected, the exact tumor extent should be determined before biopsy or surgical excision is undertaken.

U

In contrast to the WHO pathoanatomic definition, the soft tissues will be summarized from a radiodiagnostic viewpoint as those tissues that do not originate from bones or joints. In principle, all soft-tissue tumors can be manifested in the hands and are more common than bone tumors. Some entities occur at predisposed sites on the hand. The tumors are usually benign (about 15 % of all benign tumors), with ganglion cysts making up about 60 %. Malignant soft-tissue tumors of the hand are rare (about 4 % of all malignomas). Superficial tumors on the hand are noticed early by patients or their companions. These tumors are generally of epithelial origin and can often be clinically classified without additional technical examinations. Space-occupying lesions that are located deeper in the hand lead to functional impairment earlier and also to pain because of the high density of the neural network in the hand. However, there are often only uncharacteristic symptoms such as swelling, discomfort, and pain, or an ambiguous finding on clinical examination.

Diagnostic Imaging Radiography Although most of the diagnostic parameters listed in Table 45.1 cannot be evaluated with conventional radiographs, survey radiographs in two planes should be performed when a soft-tissue tumor is suspected for the following reasons:

U

U

Exclusion of a skeletal deformity, such as an exostosis (see Figs. 44.6–44.9), carpal bossing (see Fig. 28.1), or a hypertrophic callus, as the cause of the tumor. Exclusion of a secondary osseous reaction. A soft-tissue tumor can induce a periosteal reaction in the neighboring bones, bone deformity with smoothly contoured, osteosclerotic margins as a result of remodeling or scalloping (see Fig. 44.15), or bone destruction (see Fig. 44.24). Identification of calcifications in soft tissues, which can provide diagnostic evidence of, e.g., a hemangioma when phleboliths are present (see Fig. 44.3) and myositis ossificans when a dense, peripheral pattern of calcification is seen.

Ultrasonography In the search for clinically occult ganglion cysts and tissue characterization of palpable soft-tissue lesions, US examination should be performed first. Prerequisites are the application of a high-frequency probe (optimally 10–14 MHz) and an examiner with much experience in ultrasonic diagnosis of abnormalities of the hand. An advantage of US is the possibility of obtaining real-time, multiplanar scans. Disadvantages are the inadequate determination of the extent of the tumor because of bone-related shadowing if the tumor is located deep in the hand, and the often unspecific echo pattern of the tumor. Only anechoic ganglion cysts have a characteristic echo texture. In many cases, however, even the entity of neural tumors, lipomas, and vascular tumors can be determined by their echo characteristics. US makes it possible to guide a puncture real-time from the softtissue lesion.

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Soft-tissue Tumors

Computed Tomography CT is not very valuable in evaluation of the soft tissues of the hand because the absorption differences between the tumor and uninvolved soft tissues or the edema surrounding the tumor almost always provide too little contrast in comparison to the differences in signal intensity in MRI. When CT is performed, axial spiral datasets are acquired before and after contrast administration; they are computed with a soft-tissue kernel, and multiplanar reconstructions should be performed. Usually, soft-tissue tumors larger than 5 mm can be detected by means of differences in absorption, the displacement they cause, and their obliteration of compartments. There are specific CT criteria on the hand for ganglion cysts and epidermal inclusion cysts, which have the same density as water; for lipomas with density values around −100 HU; for schwannomas and neurofibromas with intense contrast enhancement; and for heterodense fibrolipomas of the median nerve. An advantage in comparison to other procedures is the sensitive identification of calcifications within the tumor.

Table 45.1 MRI parameters for the assessment of soft-tissue tumors (modified according to De Schepper) Assessment Parameter

Evaluation

Tumor size

U U U U

Tumor borders

U U U

Regional spread

U U

U

U

Signal intensity in unenhanced MRI

U U

U

Signal homogeneity in unenhanced MRI

U U U

Magnetic Resonance Imaging

Contrast enhancement

Because of its excellent soft-tissue contrast and the possibility of obtaining multiplanar images, MRI is the method of choice for the diagnosis of soft-tissue tumors of the hand: U Tumor identification: Soft-tissue tumors can be recognized by morphological criteria and alterations in signal intensity. The tumors usually lead to a lengthening in relaxation times, i.e., they appear hypointense in T1-weighted sequences and hyperintense in T2weighted sequences. Exceptions will be explained. U Tumor expansion: Tumor delineation from the surrounding edema can best be achieved with T2weighted FSE sequences (better than with T2*weighted GRE sequences), as well as with fat-saturated T1-weighted SE sequences after intravenous administration of gadolinium. Infiltrations of the bone marrow can be sensitively identified in T1-weighted images and in the STIR sequence. U Tumor entity: Many soft-tissue tumors can be classified according to MRI criteria. MRI provides characteristic appearance for ganglion cysts (signal equivalent to fluid), lipomas (hyperintense in T1-weighted and T2-weighted sequences, fat-suppressed), peripheral neural tumors (hyperintense in T2 weighted sequences, heterodense enhancement), hemangiomas (vascular convolutes with contrast enhancement), and pigmented, villonodular synovitis (hypointense hemosiderin inclusions resulting from hemorrhage). Indistinct borders and inhomogeneous signal inten-

U U U U

Pattern of contrast enhancement

U U U U

Tumor necrosis

U U

< 1 cm 1–3 cm 3–5 cm > 5 cm Smooth Partially irregular Irregular Intracompartmental Extracompartmental (second site) Infiltration of bones/ vessels/nerves Metastases Lower than muscle Between muscle and fatty tissue Higher than fatty tissue Homogeneous Mostly homogeneous Inhomogeneous None Slight Intermediate Strong Homogeneous Ring-shaped Cockade-shaped Inhomogeneous/ pleomorphic Absent Present

sity within the tumor are in many cases indicative of malignancy, although a number of malignant tumors have unspecific findings. For characterization of soft-tissue tumors in MRI diagnosis, the criteria in Table 45.1 should be analyzed and described.

Arteriography Catheter angiography is only indicated for preoperative or preinterventional diagnosis of arteriovenous malformations and highly vascular tumors to determine the arterial feeder, as well as the draining veins. The other indications for arteriography of the hand are for circulatory disturbances (Chapter 48).

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Disease Entities

Tumors of Cutaneous Origin Diagnostic Imaging

Epidermal Inclusion Cyst Pathoanatomy and Clinical Symptoms Synonyms are epithelial cysts and epitheloid cysts. The distended, elastic inclusions in the palm and on the palmar side of the fingers contain proteins, cholesterol, and lipoids; their walls are lined with squamous cells. The causation is assumed to be traumatic implantation of epidermis into the deeper layers of soft tissue. Male manual workers are most often affected.

Due to their high fat and protein content, epidermal inclusion cysts do not necessarily appear cystic in sectional images. In US examinations the interior of the cysts can be anechoic to moderately echoic, with partially inhomogeneous echogenicity. Density values in CT are over 30 HU. The high protein content leads to a moderate decrease in signal intensity in comparison to pure cysts in T2-weighted sequences and to an intermediate signal intensity in T1-weighted sequences. Peripheral contrast enhancement can be seen (Fig. 45.1). The subcutaneous location and capsular border, together with the patient’s history, indicate the correct diagnosis, though it is not possible to differentiate an epidermal inclusion cyst from an sebaceous cyst with MRI (Fig. 45.2).

a

b

c

Fig. 45.1 a–c Epithelial cysts on the palmar side of a middle phalanx. a Ultrasonic examination shows cystic structure with distal acoustic enhancement in the immediate vicinity of the flexor tendons. Due to the position and the anechoic pattern, the spaceoccupying lesion could be either an epithelial cyst or a ganglion cyst of the tendon-sheath. b The fat-suppressed T2-weighted FSE sequence reveals a hyperintense lesion in palmar-ulnar location. c After administration of gadolinium, there is peripheral enhancement of the lesion in the fatsaturated T1-weighted SE sequence. Low surrounding contrast. The pathoanatomic findings indicate a partially ruptured cyst.

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Fig. 45.2 Phalangeal sebaceous cyst as visualized in a STIR sequence. Between the cutis and the flexor tendons at the level of the middle phalanx there, is a hyperintense, sharply contoured lesion with surrounding edema.

Tumors Originating from Connective Tissue

Diagnostic Imaging

Cutaneous Carcinomas Pathoanatomy and Clinical Symptoms Almost 10 % of cutaneous malignomas are found on the hands and feet. These include squamous-cell carcinomas, which have a preferred location on the nail fold, basalcell epitheliomas, different forms of malignant melanoma with a predilection for subungual infiltration, and the rare Merkel-cell tumors.

Sectional imaging (MRI, US) only indicated for better therapy planning of advanced cutaneous carcinomas. MRI offers significant advantages for local staging because of its better soft-tissue contrast (Fig. 45.3). The depth of infiltration, especially the involvement of tendons, nerves, and blood vessels, can be determined with MRI. Staging of regional lymph nodes can be performed easily and reliably with high-resolution US.

Tumors Originating from Connective Tissue Ganglion Cyst Pathoanatomy and Clinical Symptoms This most common soft-tissue tumor of the hand (up to 6 0 %) is a accumulation of mucoid fluid within a capsule consisting of connective tissue. The pathogenesis has not been completely clarified; degeneration of periarticular connective tissue, synovial herniation, and repetitive injuries have been suggested. Ganglion cysts have no lining of synovial membrane. They are mostly found near joints and tendon sheaths. Approximately two-thirds of ganglion cysts are located on the back of the hand, with a predisposition for the immediate vicinity of the dorsal segment of the scapholunate ligament (Fig. 45.4 c). The second most common localization is the space between the ligaments of the flexor carpi radialis and the abductor pollicis longus muscles. Ulnopalmar ganglion cysts are rare, as are those originating from tendons or anular ligaments. Women and adults between the ages of 20 and 40 years are predominantly affected. About half of the gan-

glion cysts cause no complaints; the rest cause pain, dysesthesias, or functional restriction. Pressure on the ligament of origin or the distal fibers of the posterior interosseous nerve can cause chronic pain. While large ganglion cysts are easy to diagnose with palpation, the small ones, which are mostly located in the dorsal capsule, are often not discovered in clinical examination.

Diagnostic Imaging Radiographs can exclude intraosseous portions of ganglion cysts and are usually unremarkable. Refer to Chapters 23, 43, and 44 for more information on intraosseous ganglion cysts. Only large, paraosseous ganglion cysts cause periosteal and osseous reactions (scalloping) with superficial, smooth excavations, marginal osteosclerosis, and new bone formation. Clinically occult ganglion cysts at least 3 mm in size can be seen in US (Fig. 45.4 a) and MRI (Fig. 45.4 b, d, e). An advantage of MRI is that it can precisely demonstrate the surroundings of the ganglion cyst (joint capsule, tendon sheath, vessels, and nerves)

Fig. 45.3 a, b Recurrence of a Merkelcell tumor on the dorsum of the hand. A 1 cm smoothly outlined tumor in the subcutaneous fatty tissue of the carpometacarpal transition. Strong contrast enhancement. T1-weighted SE sequence a without and b with fat saturation after administration of gadolinium.

a

b

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and determine the site of origin. Table 45.2 summarizes the diagnostic criteria in MRI. The use of US first in diagnosis of ganglion cysts is recommended because of the variable choice of imaging planes and low cost. Compression under visual control in US helps to differentiate between the only slightly deformable ganglion cyst and the displaceable joint effusion. Color Doppler US remains the procedure of choice to differentiate a ganglion cyst lying next to the radial artery from an aneurysm of the vessel (see

Fig. 48.13). Occasionally, hypoechoic structures of the scapholunate joint space, the articular cartilage of the lunatum, and the dorsal radiotriquetral ligament can be confused with a ganglion cyst. Small dorsal ganglion cysts, which can cause persistent complaints, and complicated ganglion cysts following trauma or infection can be reliably detected with T2weighted MRI sequences. After administration of gadolinium there is peripheral contrast enhancement, although ganglion cysts are not lined with synovial tissue.

a

d

b

c

e

Fig. 45.4 a–e Diagnostic imaging of ganglion cysts. a US examination of a ganglion cyst on the dorsum of the wrist. The sagittal longitudinal scan shows a 9 mm anechoic structure with distal acoustic enhancement at the level of the radiocarpal joint. b MRI of a dorsal ganglion cyst with intra- and extracapsular portions. Axial T2*-weighted GRE sequence. c Diagram of a dorsal ganglion cyst originating from the scapholunate ligament. The ganglion cyst’s stalk connects the intra- and extracapsular compartments by crossing the joint capsule. d, e Ganglion cyst of the tendon sheath at the level of the proximal interphalangeal joint. The 6 mm ganglion cyst has direct contact with the flexor tendon sheath. Distinct contrast enhancement. d Plain T1-weighted SE sequence and e fatsaturated T1-weighted SE sequence after intravenous administration of a gadolinium.

c

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Tumors Originating from Connective Tissue

CT and arthrography can usually confirm transcortical communication between the extraosseous and intraosseous portions of the ganglion cysts.

Lipoma Pathoanatomy and Clinical Symptoms This fatty tumor has predisposed locations within the thenar and hypothenar muscles, as well as in the palm and on the proximal phalanges. Depending on the site of origin, endovaginal (originating from a tendon sheath) lipomas are differentiated from epivaginal ones. This soft tumor causes either no or only discrete symptoms from pressure on surrounding tissue.

Diagnostic Imaging

Table 45.2 Imaging criteria of ganglion cysts in the hand US Oval, sometimes lobulated U Smooth margins U Anechoic internal structure with distal acoustic enhancement U Internal echoes after aspiration and in long-standing ganglion cysts U Often with internal septa U

MRI Round with smooth borders U Periarticular and peritendinous locations preferred U Often connected by a stalk to the site of origin U Hyperintense in T2-weighted sequences (less intense after hemorrhage) U Hypointense in T1-weighted sequences (iso-/hyperintense when content is protein-rich) U Peripheral contrast enhancement U

CT Capsule-like margins U CT density ranging from 20 HU to 40 HU U

Large lipomas can be recognized in radiographs by a radiolucent zone – Bufalini sign (Fig. 45.5 a). Calcifications are seldom found inside the tumor. Lipomatous tissue can be reliably identified in sectional imaging: U In US, the lipomatous space-occupying lesion is homogeneously hyperechoic and deformable. U In CT, absorption values between -80 and -120 HU and the lack of contrast enhancement confirm the presence of a lipoma. U In MRI, lipomas and subcutaneous fatty tissue are characteristically hyperintense in T1- and T2-weighted sequences. The signal intensity can be suppressed by fat-saturated sequences (Fig. 45.5 b, c).

a

If the homogeneous internal structure of a lipoma is not seen in any of these imaging modalities, a liposarcoma must be excluded.

b

c

Fig. 45.5 a–c Lipoma in the hypothenar musculature. a The radiograph reveals a radiolucent lesion in the projection on metacarpals IV and V, i.e. Bufalini sign is positive.

b The T1-weighted SE sequence reveals a hyperintense, polygonal tumor in the hypothenar muscules. The T2-weighted sequence has the same signal intensity (not shown). c In the fat-suppressed T1-weighted sequence, the tumor has lost its signal.

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Fig. 45.6 a, b Fibroma originating from a flexor tendon. a The T2-weighted FSE sequence shows a 1 cm tumor with central necrosis immediately adjacent to the flexor tendon of the index finger. b Strong contrast enhancement in the T1-weighted SE sequence with fat saturation.

a

b

Fibroma

Leiomyoma

Pathoanatomy and Clinical Symptoms

Pathoanatomy and Clinical Symptoms

The tumor is solid or firm and elastic. Superficial fibromas are differentiated from deep ones, which originate from joint capsules, tendons, ligaments, and fasciae. Due to their predisposed location in the fingers, fibromas must be differentiated from Heberden nodes. A special form is the juvenile aponeurotic fibroma.

The rare leiomyoma is usually found on the dorsum of the hand, but other localizations have also been described. Leiomyomas generally cause few symptoms. The vascularized leiomyoma is a special form.

Diagnostic Imaging Fibromas tend to have plaquelike calcifications or ossifications. Depending on the size and location, a fibroma can cause pressure erosion on a neighboring bone, usually a distal finger phalanx. Fibromas are well delineated and hypoechoic in US without distal acoustic enhancement. Because of their hypoechoic appearance and preferred location, they cannot be differentiated from giantcell tumors. In CT, the fibrous portions of the tumor often cannot be well defined if there are no calcifications. In MRI a fibroma is hypointense in T1-weighted sequences with highly variable, heterogeneous contrast enhancement. In large fibromas, only the central necrotic zone is hyperintense in T2-weighted sequences (Fig. 45.6).

Diagnostic Imaging Nothing is known about the US echo pattern. A characteristic sign in CT and MRI is the strong contrast enhancement after administration of a contrast agent (Fig. 45.7).

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Tumors Originating from Connective Tissue

and foam cells, as well as pigmented macrophages. The tumor must not be confused with the osseous giant-cell tumor (osteoclastoma). This benign tumor is slightly more common among females and is manifested in adulthood. The yellowish tumor is soft with an irregular configuration and cannot be shifted against deeper layers of tissue on palpation. It generally causes no pain and only disturbs the function of the finger when it has achieved large in size. If the tumor hemorrhages into the carpus, this can cause an acute carpal tunnel syndrome. The tumor recurs in up to 20 % of cases after resection, especially when resection has been incomplete.

a

Diagnostic Imaging Radiography Pigmented villonodular synovitis appears as a spaceoccupying lesion in X-rays with the density of soft tissues. In advanced stages, it typically causes osseous erosions and the formation of subchondral cysts, by which the affected joint is often bilaterally affected.

b Fig. 45.7 a, b Leiomyoma located in the palm. a Oval, 2.2 cm tumor in the palm of the hand. The hypointense area within the tumor is caused by an enclosed flexor tendon. Plain T1-weighted SE sequence. b The axial sequence after administration of gadolinium (T1weighted SE sequence with fat saturation) shows strong enhancement and the origin of the tumor from a lumbrical muscle. The flexor digitorum superficialis tendon of the index finger is enclosed in the tumor and displaced in palmar direction.

Ultrasonography Giant-cell tumors can usually be well delineated in US. Their internal structure is hypoechoic without distal acoustic enhancement. It is often impossible to differentiate a giant-cell tumor from a fibroma.

Computed Tomography Aside potential pressure erosions, an inhomogeneous soft-tissue mass can be visualized in CT.

Giant-cell Tumor of the Tendon Sheath (“Xanthoma”) Pathoanatomy and Clinical Symptoms Synonyms are pigmented villonodular synovitis (PVNS) and xanthoma. This second-most-common soft-tissue tumor of the hand originates from the tendon sheaths of finger flexors II–IV and the capsules of the carpal and finger joints, especially the distal interphalangeal joints. Here the nodular or polypoid space-occupying lesion can infiltrate into the lateral finger septum with palmar and dorsal spread. The granulomatous tumors consist of a mixture of foreign-body giant cells, spindle-shaped cells,

Magnetic Resonance Imaging Characteristics of giant-cell tumors (pigmented villonodular synovitis) are their periarticular or peritendinous location, their smooth contours, and low signal in both T1-weighted and T2-weighted sequences (Fig. 45.8). The signal intensity depends on the paramagnetic effect of hemosiderin in the macrophages, which is the result of previous bleeding within the tumor. There are also areas with fatty inclusions of high signal intensity. The same inhomogeneous signal intensity is found in the giant-cell tumor of the bone.

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Aggressive Fibromatosis (Desmoid Tumor) Pathoanatomy and Clinical Symptoms These tumors, which usually contain collagen substance but few cells, originate from the connective tissue of the muscles, fasciae, and aponeuroses and display aggressive local growth with infiltration of the surrounding tissues. The recurrence rate is high, but there are no metastases. Aggressive fibromatosis, which is solid on palpation, is rarely found in the hand.

a

Diagnostic Imaging Aggressive fibromatosis can cause pressure erosions on the cortical bone. Its CT density values coincide with those of muscle (approx. 50 HU). The relationship of the tumor to surrounding tissues can be determined with CT, e.g., expansion into the intermetacarpal spaces (Fig. 45.9), but the infiltrative character is best documented with MRI. In T1-weighted sequences, aggressive fibromatosis has mainly areas of intermediate signal intensity interspersed with areas of hypointense signal and inhomogeneous contrast enhancement. The tumor is hyperintense in T2-weighted sequences.

b Fig. 45.8 a, b Giant-cell tumor (pigmented villonodular synovitis) originating from the flexor-digitorum tendons of the index finger. a The axial T2*-weighted GRE sequence reveals that a 1.8 cm mass of intermediate signal intensity broadly surrounds the flexor tendons from the palmar side. Punctate inclusions of lower signal intensity are caused by hemosiderin deposits. b Intense contrast enhancement in the fat-saturated T1weighted SE sequence. Additionally, hypointense inclusions are detectable in the tumor mass.

Fig. 45.9 CT of aggressive fibromatosis of the dorsum of the hand. The tumor mass in dorsal location (density 50 HU) broadly infiltrates intermetacarpal spaces II/III, displaces the third extensor tendon, and undermines flexor tendons II and III.

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Tumors Originating from Connective Tissue

Computed Tomography

Soft-tissue Sarcomas Pathoanatomy and Clinical Symptoms Sarcomas are malignant tumors originating from mesenchymal tissues. They are rarely found in the hand. U The most common is the epitheloid sarcoma. Pathoanatomically, this tumor is characterized by the simultaneous presence of nodules of large epitheloid cells, central necroses, and spindle-shaped cells in the periphery. The solitary or multiple nodules are solid and connected to tendon sheaths or the palmar aponeurosis. They infiltrate neighbored bones and skin early and have a high rate of recurrence. U The synovial sarcoma, which occurs most commonly in middle age and predominately affects the extremities, originates from the synovium of joints or tendon sheaths. This tumor has a poor prognosis because it metastasizes early. U The fibrosarcoma can develop primarily or secondarily from precancerous lesions, such as scars or after irradiation (Chapter 35). In imaging procedures, the fibrosarcoma cannot be differentiated from the malignant fibrous histiocytoma. Both tumors can be surrounded by a reactive pseudocapsule of connective tissue, which can cause confusion with a benign softtissue mass. U Liposarcomas, whose degree of malignancy correlates with the fibrous portion of the tumor, and rhabdomyosarcomas appear very rarely in the hand.

In comparison to MRI, axial CT is clearly limited in its capability of determining the extent of malignant tumors. CT is indicated to identify calcifications in tumors and tumor infiltration into bones.

Magnetic Resonance Imaging Determination of the tumor spread and infiltration into surrounding tissues (e.g., encasement of neurovascular structures) is most successful with the use of high-resolution contrast-enhanced MRI. Almost all sarcomas have low to intermediate (isointense to muscle) signal intensity in T1-weighted sequences and are hyperintense in T2-weighted sequences (Figs. 45.10, 45.11). Their inhomogeneous structure with central necroses and indistinct borders, which can have continuous transitions into perifocal edema, is characteristic. The border between tumor and edema can best be identified with T2-weighted sequences or contrast-enhanced T1-weighted sequences. MRI criteria can be used to determine the maligancy of a soft-tissue tumor on the hand with relative certainty. Determination of the pathoanatomic tumor entity involved is generally not possible, however. Table 45.3 summarizes the diagnostic criteria of the three most common soft-tissue sarcomas.

Table 45.3 Distinguishing features among soft-tissue sarcomas Epitheloid sarcoma: Predominantly in early childhood U Solitary or multiple nodules U Possible tumor calcification U

Diagnostic Imaging Radiography

Synovial sarcoma: Predominantly in early adulthood U Periarticular and peritendinous locations U Usually smooth tumor margins U Calcifications in 15 % of cases U

Infiltration of sarcomas into adjacent bone tissue is very rare. The tumor matrix of malignant fibrous histiocytomas occasionally contains calcifications.

Malignant fibrous histiocytoma/fibrosarcoma: Only in the elderly U Heterogeneous structure due to hemorrhage and necroses (especially in T2- weighted sequences) U Growth along fasciae U Note: pseudocapsules are possible! U

Ultrasonography Sarcomas are hypoechoic in US; tumor necroses can be identified. The extent of the tumor cannot reliably be determined in the deep tissue layers of the hand.

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b Fig. 45.10 a, b Synovial sarcoma in the palm and carpal tunnel. Contrast-enhanced T1-weighted axial and coronal SE sequences. The tumor with inhomogeneous contrast enhancement reveals extensive necroses. The tumor originates from the flexor tendon

a

sheath of the index finger. The other flexor tendons are displaced. The tumor has expanded into the carpal tunnel and has reached the immediate vicinity of the palmar cutis.

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Fig. 45.11 a, b Fibroblastic myxo-inflammatory sarcoma of the distal forearm. a A hyperintense, space-occupying lesion on the ulnar side of direction. The tumor is growing between the flexor carpi the palmar forearm is visible in the T2*-weighted GRE ulnaris muscle and the finger flexors. sequence. The indistinct tumor borders indicate infiltration b The fat-saturated T1-weighted SE sequence shows central of the pronator quadratus muscle. The flexor tendons as well tumor necroses. The tumor periphery is well vascularized. as the ulnar neurovascular bundle are displaced in palmar

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Tumors Originating from Blood Vessels and Lymphatic Vessels

Tumors Originating from Blood Vessels and Lymphatic Vessels Table 45.4 shows the classification of vascular tumors and malformations.

Diagnostic Imaging Radiography

Hemangiomas Pathoanatomy and Clinical Symptoms Pathoanatomically, hemangiomas represent a broad spectrum of vascular tumors with capillary, cavernous, venous, or arteriovenous components, but also with mesenchymal tissue of nonvascular origin. These relatively common vascular tumors of the hand usually have cutaneous or subcutaneous locations and, less often, are found in tendon sheaths, muscles, or the median nerve. Women are most often affected, and incidence peaks in early adulthood. A familial disposition is probable. U Purely cavernous hemangiomas are built of large vascular spaces subdivided by septa and lined with endothelium. Slow blood flow and thrombosed angiomatous areas are characteristic. U Arteriovenous (AV) malformations are rarely observed on the hand. These so-called high-flow angiomas bypass the normal capillary bed. AV fistulas have thick endothelial layers. They often cause no clinical symptoms. U Semimalignant hemangioendotheliomas are also rarely found on the hand. Like AV malformations, they are lined with a thick layer of endothelium and cause only a few symptoms. U The Klippel–Trénaunay syndrome is an independent disease entity in which hemangiomas are accompanied by unilateral hypertrophy of an extremity.

Benign vascular tumors U Localized hemangiomas: capillary, cavernous, venous, arteriovenous (AVM) U Angiomatosis

Malignant vascular tumors U Angiosarcoma U Kaposi sarcoma

Arteriography Catheter angiography is very useful in demonstrating arterial feeders and drainage veins within arteriovenous high-flow malformations (see Fig. 48.19). Information on the vascular supply is essential for planning complete resection of these tumors. The so-called nidus of a hemangioma appears as a spotty accumulation of contrast medium (pooling) in the late-arterial phase. In the more common cavernous and capillary forms, the entire extent of the hemangiomas is, in contrast, considerably underestimated in arteriograms. Because of the slow blood flow and thrombotic occluded vessel lumina, these hemangiomas usually cannot be seen at all in the arterial phase. Parts of the angioma first show contrast enhancement in the parenchymal phase.

Computed Tomography Intravenous administration of a contrast agent leads to strong enhancement of vascular tumors. Contrast filling defects indicate either partial thrombosis of the hemangioma or, if located within a neurovascular bundle, a vascular sheathing of the nerve with unmasking of its fascicles.

Magnetic Resonance Imaging

Table 45.4 Classification of vascular tumors (shortened according to Enzinger and Weiss)

Semimalignant vascular tumors U Hemangioendotheliomas: epithelioid, spindle-cell, papillary

Radiographs often provide little information. Phleboliths are sometimes seen in hemangiomas; linear or arched calcifications on the vascular walls are less common. Special forms are the Maffucci syndrome as a combination of a hemangioma with enchondromatosis (see Fig. 44.3) and the Klippel–Trénaunay syndrome, which leads to macrodactyly of one or more fingers.

The entire expansion of a vascular tumor and its topographic location can best be determined with the use of contrast-enhanced MRI. Ideally, during a single examination, temporally-resolved MR angiography recording the flow of a contrast bolus for at least one minute (Fig. 45.12 a, b) is combined with MR sectional imaging (Fig. 45.12 c). In T2-weighted sequences, a hemangioma has more distinct borders than in plain T1-weighted sequences, in which the vascular tumor appears isointense to muscle tissue and cannot be well delineated when it is intramuscularly located within a muscle. An inhomogeneous

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Fig. 45.12 a–c Extramuscular hemangioma on the radial side of the forearm. Maximal intensity projection (MIP) reconstructions of dynamic MR angiography. a During the arterial phase, only parts of the angioma are filled.

pattern of signal intensity caused by different tissue components is characteristic: U Interspersed mesenchymal tissue is usually heterointense, e.g., fatty tissue in T1- and T2-weighted sequences is hyperintense, whereas phleboliths and calcifications are hypointense. U Thrombotic vessel segments have different signal intensities depending on thrombotic age. U Visualization of vessel lumina within the vascular tumor depends decisively on the rate of blood flow and the type of sequence applied. In T2-weighted images, fast blood flow generally causes a flow void with a dark

b Further filling occurs during the venous phase 40 seconds later. c Seven minutes after application of gadolinium, the fatsaturated T1-weighted SE sequence reveals patchy angioma convolutes only in the subcutaneous fatty tissue.

lumen, whereas a slow or stagnant flow in dilated or tortuous vessels can cause a marked signal (paradoxical enhancement). There can even be a combination of different types of blood flow. T1-weighted images should always be acquired after intravenous application of gadolinium, preferably with a fat-saturation pulse and a delay of a few minutes. Contrast-enhanced T1-weighted sequences precisely demonstrate the extent of the vascular tumor (Figs. 45.12, 45.13) and occasionally even show the arterial feeders and draining veins.

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Tumors Originating from Blood Vessels and Lymphatic Vessels

Malignant Vascular Tumors Pathoanatomy and Clinical Symptoms Malignant vascular tumors are very rare on the hand. Two forms are pathohistologically differentiated. An angiosarcoma can often only be differentiated with difficulty from the more benign hemangioendothelioma or hemangiopericytoma. Angiosarcomas have a locally aggressive growth with osseous infiltration and tend to metastasize. Kaposi sarcoma appears frequently in patients infected with HIV and is initially manifested by blue-red, painless cutaneous nodules that later confluence and become soft.

Diagnostic Imaging When signs of destruction and metastasis are absent, none of the imaging procedures can differentiate malignant from benign hemangiomas.

Fig. 45.13 Cavernous hemangioma in the palm. A grape-shaped hemangioma located between the flexor tendons in the carpal tunnel and the metacarpus, as well as within the adductor pollicis muscle. T1-weighted SE image with fat saturation 10 minutes after intravenous administration of gadolinium.

Glomus Tumor Pathoanatomy and Clinical Symptoms This neurovascular tumor is only a few millimeters in diameter and is usually found in the nail bed and fingertip, where it shines through the skin or nail with a reddish-blue color. It is rarely found in a purely intraosseous location. Pathoanatomically, this is a vascular convolute with multiple arteriovenous shunts. Spherical glomus cells, nets of neural fibers, and Vater–Pacini bodies surround the afferent arteries. These tumors can cause attacks of the severest pain.

Diagnostic Imaging The typical radiographic sign is a pressure erosion on the distal phalanx with a osteosclerotic margin (Fig. 45.14 a). In extraosseous locations, high-frequency US can be indicative of the presence of a glomus tumor. The glomus tumor appears as a round, hypoechoic, sharply defined lesion (Fig. 45.15). MRI is undoubtedly the imaging procedure of choice to precisely locate a glomus tumor in the distal phalanx and to provide a definitive diagnosis based on the high degree of vascularization in combination with the clinical appearance (Fig. 45.14 b, c).

Lymphangiomas Pathoanatomy and Clinical Symptoms Hamartomatous lymphangiomas are rare on the hand. U The most common is the lymphangioma simplex, which appears as a single blister or a group of small blisters containing yellowish-gray lymphatic fluid. U The cavernous lymphangioma, in which the cystic spaces are filled with lymph or blood, can be associated with macrodactyly. U The cystic lymphangioma is characteristically outlined with a thick layer of connective tissue.

Diagnostic Imaging Sectional imaging displays all criteria of cystic tumors. Due to the high lipid content of the lymphatic fluid, CT density values are negative. In T1-weighted MRI sequences the signal intensity is intermediate. T2-weighted sequences are typically hyperintense (Fig. 45.16). The diagnosis is generally based on puncture results.

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Fig. 45.14 a–d Glomus tumor on the fingertip. a The dorsopalmar radiograph shows an osteolysis with sharp margins on the ungual tuberosity. b In this position, the tumor appears extremely hyperintense in the fat-saturated PD-weighted FSE sequence. c, d Plain sagittal T1-weighted SE sequence (c) and fat-saturated T1-weighted sequence following administration of gadolinium (d). The tumor, which appears hypointense in plain MRI, shows intense contrast enhancement.

a

a

c

b

d

b

Fig. 45.15 a, b US of a subungual glomus tumor. a Dorsal longitudinal section along the distal phalanx. b Cross-section of the distal phalanx. Between the measuring points there is a 5 mm, hypoechoic lesion with smooth margins on the ungual tuberosity. (Courtesy of B. Fornage, MD, Houston, TX)

Fig. 45.16 Recurrence of a congenital lymphangioma. Because of multiple recurrences with trophic disturbances, fingers II–V have already been resected at the level of the carpometacarpal joints. There is now a recurrence with small, honeycombed, cystic inclusions on the ulnar side of the stump of the hand. T2-weighted FSE image with fat saturation.

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Tumors Originating from Neural Tissue

Tumors Originating from Neural Tissue Neurinoma (Schwannoma) and Neurofibroma Pathoanatomy and Clinical Symptoms Among tumors of the nerve sheath, neurinomas are differentiated from neurofibromas by their different sites of origin and their position in relation to the nerve affected. There may be no symptoms, however both neurogenic tumors can cause paresthesia and hypesthesia, localized pain, and pareses in their areas of distribution. U Neurinomas, which are located primarily on the palmar side, arise from Schwann cells of the endoneurium, perineurium, or epineurium. Since only one nerve fascicle is usually affected, the tumor is eccentric to the nerve of origin. In addition to areas rich in cells arranged like a palisade (Antoni A) and areas with few cells (Antoni B), cystic inclusions are found that result from hyaline or myxoid degeneration. The tumor is surrounded by a capsule of connective tissue. U Neurofibromas cause diffuse thickening of the nerve sheath. For this reason, the nerve fascicle runs through the concentric tumor. Cystic inclusions are seen in half of cases. A subtype is the plexiform neurofibroma.

a

b

c

d

Neurofibromas have no capsule. They occur as solitary tumors or in conjunction with Recklinghausen neurofibromatosis. Over 15 % of these tumors become malignant.

Diagnostic Imaging Radiography Paraosseous neurogenic tumors can cause pressure erosions in the bone (scalloping). Few neurinomas display plaquelike calcifications.

Ultrasonography US provides valuable information about the nerve sheath tumors. Both neurinomas and neurofibromas are hypoechoic with well-defined margins and contain anechoic cysts with distal acoustic enhancement. They can be differentiated in only about 50 % of cases by their position in relation to the nerve of origin. Neurinomas are typically eccentric, whereas neurofibromas are concentric in relation to the affected nerve. The Hoffmann–Tinel sign (disFig. 45.17 a–d Plexiform neurofibroma causing impaired sensitivity, and positive Hoffmann–Tinel sign in the area innervated by the median nerve. a Hyperintense, encapsulated tumor palmar to the adductor pollicis muscle. Whorls of inhomogeneous signal intensity in the axial T2-weighted FSE sequence. b Marked but inhomogeneous contrast enhancement in the axial T1-weighted SE sequence. c, d Coronal T1-weighted SE sequences before (c)and after (d) gadolinium application. The oval tumor shows only peripheral contrast enhancement. The center has signs of myxoid degeneration. The tumor is located between the flexor pollicis longus tendon and the flexor tendons of the index finger.

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tal paresthesia in the distribution of the nerve provoked by percussion over the site of compression) can be elicited during the US examination.

Computed Tomography In the unenhanced CT scan, neural tumors appear hypodense with values between 35 and 50 HU. In principle, the inhomogeneous contrast enhancement after intravenous administration of gadolinium is comparable with the appearance in MRI.

the flexor tendons and bulging of the flexor retinaculum. In macrodystrophia lipomatosa (Fig. 45.19) there is a combination of fibrolipomatous hypertrophy of the median nerve and gigantism of one or more fingers within its area of distribution. Characteristically, increased fatty tissue is found in the nerve, muscle, and bone marrow.

Malignant Neurinoma (Neurofibrosarcoma)

Magnetic Resonance Imaging

Pathoanatomy and Clinical Symptoms

Identification of the affected nerve from which the tumor originates can be attempted with MRI because of its multiplanar imaging capability. The neural tumor itself has a characteristically inhomogeneous pattern of enhancement after intravenous administration of gadolinium. Aside from hypervascularized areas containing many cells, there are areas in the periphery or the center of the tumor with cystic or xanthomatous degeneration with no contrast enhancement (Fig. 45.17). In T2weighted sequences, both types of tumor display moderate to high signal intensity; a target configuration is indicative of a neurofibroma. An inhomogeneous signal in the center of the tumor should not primarily be interpreted as a sign of malignancy.

Malignant neural tumors can appear in isolation or in association with Recklinghausen neurofibromatosis. The degree of malignancy increases with the cell density and cellular pleomorphism of the neural tumor. These tumors display perineural growth in a proximal direction and tend toward hematogenous metastases.

Diagnostic Imaging Because of their inhomogeneous internal structure, benign neural tumors generally cannot be differentiated from malignant ones with the help of imaging procedures. The most important diagnostic task is, therefore, to determine the proximal tumor border, and this determination can best be achieved with contrast-enhanced MRI.

Intraneural Fibrolipoma Posttraumatic Neuroma

Pathoanatomy and Clinical Symptoms This tumor-like hyperplasia of the nerve is rare and primarily affects the median nerve in the carpal tunnel of young men. It can cause a chronic carpal tunnel syndrome. These tumors are thought to originate from the fat cells of the epineurium, i.e., the tumor originates, like intraneural lipomas, hemangiomas, and ganglion cysts, from the stromal tissue of the peripheral nerve. This benign space-occupying neural lesion can occur together with macrodactyly, especially of the index and middle fingers (macrodystrophia lipomatosa).

Pathoanatomy and Clinical Symptoms This is not actually a tumor but a neural scar formation with disorganized proliferation of neural tissue and axonal and perineural regenerative processes at the proximal end of an injured nerve. The cause is severance of a nerve or chronic irritation of an intact nerve (pseudoneuroma). In addition to hypesthesias and dysesthesias, piercing pain (phantom pain) is often felt in the missing limb after amputation.

Diagnostic Imaging

Diagnostic Imaging

This heterogeneous tumor consisting of neural and connective tissue has a characteristic appearance in MRI. The hypertrophic nerve fascicles have tortuous courses within the lipomatous tissue, which can easily be recognized by its signal intensity (Fig. 45.18). The neural fibrolipoma, which usually extends from the distal forearm to the metacarpus, causes lateral displacement of

In US, posttraumatic neuromas appear as hypoechoic, usually poorly defined tumors in which directed palpation can provoke trigger points with electrifying discomfort. In contrast-enhanced MRI, a neuroma shows homogeneous low enhancement (Fig. 45.20). Multiplanar slices in MRI help to identify the neurovascular bundle affected by the neuroma and, thereby, the nerve of origin.

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Tumors Originating from Neural Tissue

a Fig. 45.18 Fibrolipomatous hypertrophy of the median nerve. In the T1-weighted SE sequence, there are thickened and elongated nerve fascicles within the hyperintense fatty tissue. The flexor tendons are displaced.

b Fig. 45.19 a, b Macrodystrophia lipomatosa of the thumb and index finger rays. In the palm, the median nerve (arrows) is massively enlarged and interspersed with fatty tissue. Lipomatous transformation of the thenar musculature, the adductor pollicis muscle, the first interosseous muscles, and the first lumbrical muscle. Distinct increase in volume of the radial metacarpus. a Axial T1weighted SE sequence and b coronal T2-weighted FSE sequence. Fig. 45.20 a, b Posttraumatic neuroma of the median nerve 18 years after a cut injury.

a Spindle-shaped swelling of the median nerve in the distal forearm. Fat-saturated T1-weighted SE sequence, sagittal image after administration of gadolinium.

b Axial T2-weighted FSE sequence shows a diskshaped, hyperintense space-occupying lesion between the flexor pollicis longus and the flexor digitorum superficialis muscles and the tendon of the flexor carpi radialis muscle.

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Differential Diagnosis Many soft-tissue tumors of the hand have a predilection for certain locations and patterns of appearance. Among these are ganglion cysts, epidermal inclusion cysts, lipomas, hemangiomas, glomus tumors, and tumors of

the nerve sheaths. In contrast, the remaining mesenchymal tumors, such as sarcomas and the desmoid tumor, have uncharacteristic findings. The diagnosis can only be made on the basis of biopsy results.

Therapeutic Options Ganglion cysts are treated by surgical extirpation, in which the stalk connecting the cyst to the synovial tissue of origin should always be ligated. The other benign softtissue tumors of the hand are also removed surgically if they cause functional disorder. If a neurological deficit arises after removal of a neural-sheath tumor, surgical replacement of neural tissue may be necessary in an attempt at reinnervation of the damaged nerve. Because they tend to recur, giant-cell tumors of the nerve sheath (xanthomas) and the semi-malignant, aggressive fibromatosis should be radically extirpated. Soft-tissue sarcomas are treated by excision with wide margins toward the nontumorous tissue, if possible, or by amputation. The indication for preoperative radiotherapy and/or complementary chemotherapy depends on the disease entity and the tumor stage. The same applies to subsequent surgery to restore function of the hand.

Further Reading Anderson SE, Steinbach LS, Stauffer E, Voegelin E. MRI for differentiating ganglion and synovitis in the chronic painful wrist. Am J Roentgenol. 2006;186;812–818. Angelides AC. Ganglions of the hand and the wrist. In: Green DP, ed. Operative Hand Surgery. 4th ed. New York: Churchill Livingstone; 1999:2171–2183. Binkovitz LA, Berquist TH, McLeod RA. Masses of the hand and wrist: Detection and characterization with MR imaging. Am J Roentgenol. 1990;154:323–326. Bhatti AM, Alo GO, Power DM, Masood A, Thuse MG. Lobulated schwannoma of the median nerve: Pitfalls in diagnostic imaging. J Comput Assist Tomogr. 2005;29:330–332. Blam O, Bindra R, Middleston W, Gelberman R. The occult dorsal ganglion: Usefulness of magnetic resonance imaging and ultrasound in diagnosis. Am J Orthop. 1998;27:107–110. Boudghene FP, Gouny P, Tassart M, Callard P, Le Breton C, Vayssairat M. Subungual glomus tumor: Combined use of MRI and threedimensional contrast MR angiography. J Magn Reson Imag. 1998;8: 1326–1328. Campanacci M. Bone and Soft Tissue Tumors. Heidelberg: Springer; 1999. Capelastegui A, Astigarraga E, Fernandez-Canton G, Saralegui I, Larena JA, Merino A. Masses and pseudomasses of the hand and wrist: MR findings in 134 cases. Skeletal Radiol. 1999;28:498–507. Cardinal E, Buckwalter KA, Braunstein EM, Mih AD. Occult dorsal carpal ganglion: Comparison of US and MR imaging. Radiology. 1994; 193:259–262. Chinyama CN, Roblin P, Watson SJ. Evans DM. Fibromatoses and related tumors of the hand in children. A clinicopathologic review. Hand Clin. 2000;16:625–635.

Cohen EK, Kressel HY, Perosio T et al. MR imaging of soft-tissue hemangiomas: Correlation with pathologic findings. Am J Roentgenol. 1987;150:1079–1081. De Beuckeleer L, De Schepper A et al. Magnetic resonance imaging of localized giant cell tumour of the tendon sheath (MRI of localized GCTTS). Eur Radiol. 1997;7:198–201. De Schepper AMF, ed. Imaging of Soft-tissue Tumors. Heidelberg: Springer; 1997. Drape JL, Idy-Peretti I, Goettmann S et al. MR imaging of digital mucoid cysts. Radiology. 1996;200:531–536. Llauger J, Palmer J, Roson N, Cremades R, Bague S. Pigmented villonodular synovitis and giant cell tumors of the tendon sheath: Radiologic and pathologic features. Am J Roentgenol. 1999;172: 1087–1901. el-Noueam KI, Schweitzer ME, Blasbalg R et al. Is a subset of wrist ganglia the sequela of internal derangements of the wrist joint? MR imaging findings. Radiology. 1999;212:527–540. Enzinger FM, Weiss SW. Soft Tissue Tumors. 2nd ed. St Louis: Mosby; 1988. Feldman F, Singson RD, Staron RB. Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiol. 1989;18: 353–358. Fornage BD. Glomus Tumors in the Fingers: Diagnosis with US. Radiology. 1988;167:183–185. Francis IR, Dorovini-Zis K, Glazer GM, Lloyd RV, Amendola MA, Martel W. The fibromatoses: CT-pathologic correlation. Am J Roentgenol. 1986;147:1063–1066. Garcia J, Bianchi S. Diagnostic imaging of tumors of the hand and wrist. Eur Radiol. 2001;11:1470–1482. Goldman AB, Kaye JJ. Macrodystrophia lipomatosa: Radiography. Am J Roentgenol. 1977;128:101–105. Llauger J, Palmer J, Roson N, Cremades R, Bague S. Pigmented villonodular synovitis and giant cell tumors of the tendon sheath: radiologic and pathologic features. Am J Roentgenol. 1999;172: 1087–1091. Hawnaur J, Whitehouse R, Jenkins J, Isherwood I. Musculoskeletal hemangiomas: comparison of MRI with CT. Skeletal Radiol. 1990; 19:251–258. Heiken JP, Lee JKT, Smathers RL, Totty WG, Murphy WA. CT of benign soft-tissue masses of the extremities. Am J Roentgenol. 1984;142: 575–580. Hoglund M, Tordai P, Muren C. Diagnosis of ganglions in the hand and wrist by sonography. Acta Radiol. 1994;35:35–39. Horcajadas AB, Lafuente JL, de la Cruz Burgos R et al. Ultrasound and MR findings in tumor and tumor-like lesions of the fingers. Eur Radiol. 2003;13:672–685. Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AA, Malawer MM. Giant cell tumor of the tendon sheath: MR findings in nine cases. Am J Roentgenol. 1994;162:919–922. Karasick D, Karasick S. Giant cell tumor of tendon sheath: Spectrum of radiologic findings. Skeletal Radiol. 1992;21:219–224. Kim EY, Ahn JM, Yoon HK et al. Intramuscular vascular malformations of an extremity: Findings on MR imaging and pathologic correlation. Skeletal Radiol. 1999;28:515–521.

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Therapeutic Options

Kransdorf MJ, Moser RP Jr, Meis JM, Meyer CA. Fat containing soft tissue masses of the extremities. Radiographics. 1991;11:81–106. Kransdorf MJ. Malignant soft-tissue tumors in a large referral population: Distribution of diagnoses by age, sex, and location. Am J Roentgenol. 1995;164:129–134. Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue masses: A current perspective. Am J Roentgenol. 2000;175: 575–587. Lin J, Jacobson JA, Hayes CW. Sonographic target sign in neurofibromas. J Ultrasound Med. 1999;18:513–517. Lin J, Fessell DP, Jacobson JA, Weadock WJ, Hayes CW. An illustrated tutorial of musculoskeletal sonography: Part IV. Musculoskeletal masses, sonographically guided interventions, and miscellaneous topics. Am J Roentgenol. 2000;175:1711–1719. Mahajan H, Lorigan JG, Shirhoda A. Synovial sarcoma: MR imaging. Magn Reson Imag. 1989;7:211–216. Meyer BU, Röricht S, Schmitt R. Bilateral fibrolipomatous hamartoma of the median nerve with macrocheiria and late-onset nerve entrapment syndrome. Muscle & Nerve. 1998;21:656–658. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: Analysis of sonographic findings. Am J Roentgenol. 2004;183:337–339. Miller TT, Potter HG, McCormack Jr RR. Benign soft tissue masses of the wrist and hand: MRI appearances. Skelet Radiol. 1994;23: 327–332. Mirowitz SA, Totty WG, Lee JKT. Characterization of musculoskeletal masses using dynamic Gd-DTPA enhanced spin-echo MRI. J Comput Assist Tomogr. 1992;16:120–125. Morton MJ, Berquist TH, McLeod RA, Unni KK, Sim FH. MR imaging of synovial sarcoma. Am J Roentgenol. 1991;156:337–340. Ogose A, Hotta T, Morita T et al. Tumors of the peripheral nerves: Correlation of symptoms, clinical signs imaging features and histologic diagnosis. Skeletal Radiol. 1999;28:123–128. Peh WC, Truong NP, Totty WG, Gilula LA. Pictoral review: Magnetic resonance imaging of benign soft tissue masses of the hand and wrist. Clin Radiol. 1995;50:519–525.

Reynolds DL, Jacobson JA, Inampudi P, Jamadar DA, Ebrahim FS, Hayes CW. Sonographic characteristics of peripheral nerve sheath tumors. Am J Roentgenol. 2003;182:741–749. Schmitt R, Warmuth-Metz M, Lanz U, Lucas D, Feyerabend T, Schindler G. Computed tomography of soft tissue tumors of the hand and the forearm. Radiologe. 1990;30:185–192. Schmitt R, Wuttke V, Buchner U, Preger R. The diagnosis of posttraumatic neuroma via sonography and CT . Fortschr Röntgenstr. 1990; 152:180–184. Sherry CS, Harms SE. MR evaluation of giant cell tumors of the tendon sheath. Magn Res Imag. 1989;7:195–201. Steinbach LS. Tumors and synovial processes in the wrist and hand. In: Reicher MA, Kellerhouse LE, eds. MRI of the Wrist and Hand. New York: Raven Press; 1992:129–156. Sundaram M, McGuire MH, Fletcher J, Wolverson MK, Heiberg E, Shields JB. Magnetic resonance imaging of lesions of synovial origin. Skeletal Radiol. 1986;15:110. Sundaram M, McLeod RA. MR imaging of tumor and tumorlike lesions of bone and soft tissue. Am J Roentgenol. 1990;155:817–824. Theumann NH, Bittoun J, Goettmann S, Le Viet D, Chevrot A, Drape JL. Hemangiomas of the fingers: MR imaging evaluation. Radiology. 2001;218:841–847. Theumann NH, Goettmann S, Le Viet D et al. Recurrent glomus tumors of fingertips: MR imaging evaluation. Radiology. 2002:223: 143–151. Toms AP, Anastakis D, Bleaknev RR, Marshall TJ. Lipofibromatous hamartoma of the upper extremity: A review of the radiologic findings for 15 patients. Am J Roentgenol. 2006;186:805–811. Wiesmann W, Galanski M, Peters P, Timm C. Radiological diagnosis of aggressive fibromatosis. Fortschr Röntgenstr. 1986;145:555–559. Weiss SW, Goldblum JR. Enzinger and Weiss’ Soft Tissue Tumors. 4th ed. St. Louis: Mosby; 2001. Yung BCK, Loki TKL, Chan YL. Angiomatosis of the hand demonstrated by contrast-enhanced magnetic resonance angiogram. Austral Radiol. 2000:44:198–200.

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Carpal Tunnel Syndrome W. Buchberger, R. Schmitt

Carpal tunnel syndrome is a neuropathy of the median nerve caused by compression of the nerve within the carpal canal. The most common cause found intraoperatively is degenerative or inflammatory thickening of the flexor tendon sheaths. Radiography should always be performed to exclude osseous stenosis of the carpal tunnel due to malalignment of the carpal bones. Sectional-imaging studies are required only when the situation remains equivocal: US to visualize

the median nerve; CT when there is suspicion of an osseous carpal stenosis or an acute calcium deposit, and MRI to determine the nature and extent of space-occupying soft-tissue lesions within the carpal canal. These three procedures can demonstrate changes in the shape resp. signal intensity of the median nerve caused by compression. When postsurgical complaints persist, MRI is the evaluation method of choice.

Preliminary Remarks on Anatomy FR RF

a

MN

FPL

FCR

FDS FDP

b

FDS FDP

c PD VD

FR RF

MN

FPL

FCR

The carpal tunnel is a 2.5 cm-long osteofibrous canal on the palmar side of the carpus that contains the tendons of the finger flexors and the FCR and the median nerve (Fig. 46.1, Table 46.1). In the proximal section, the floor is formed by the capitate, hamate, and triquetrum. The radial wall is formed by the scaphoid, and the ulnar wall by the pisiform. The palmar side is bordered by the flexor retinaculum (transverse carpal ligament), which attaches to the tubercle of the scaphoid and the pisiform. The carpal tunnel is narrower in its distal section and is located deeper in the carpus. The distal floor section is formed by the capitate and trapezoid, the radial wall by the trapezium, and the ulnar wall by the hook of the hamate. The flexor retinaculum is thickest in the distal portion and inserts on the tubercle of the trapezium and the hook of the hamate. The tendons of the flexor digitorum superficialis and flexor digitorum profundus muscles run within a com-

Fig. 46.1 a–c Diagram of cross-sectional anatomy of the carpal tunnel. Abbreviations: FR = flexor retinaculum; MN = median nerve; FDS and FDP = tendons of the flexor digitorum superficialis and flexor digitorum profundus muscles; FCR = tendon of the flexor carpi radialis muscle; FPL = tendon of the flexor pollicis longus muscle. a Axial scan at the entrance to the carpal tunnel at the level of the pisiform. b Axial scan at the exit of the carpal tunnel at the level of the hook of the hamate. c Diagram for determination of the palmar deviation (PD) of the flexor retinaculum. It is the distance from the maximal bulge of the flexor retinaculum to the line connecting the tubercle of the trapezium with the hook of the hamate.

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Pathophysiology and Clinical Symptoms

mon tendon sheath in two rows, one over the other. The tendon of the flexor pollicis longus muscle has its own sheath, which communicates with the synovial sac of the other flexors in 50 % of cases. This sheath lies radial of the aforementioned tendon sheath. The tendon of the flexor carpi radialis muscle lies outside the actual carpal tunnel along the trapezium and between the layers of the flexor retinaculum. The median nerve is located immediately below the flexor retinaculum and, very variably, usually radial of the middle line. Before entering the carpal tunnel the median nerve gives off its sensory palmar branch, and within the tunnel motor branches for the abductor pollicis brevis, the opponens pollicis, the superficial head of the flexor pollicis brevis, and the two ulnar-sided lumbrical muscles.

Table 46.1 Anatomic boundaries of the carpal tunnel Boundary

Carpal Tunnel Entrance

Carpal Tunnel Exit

Floor

Capitate Hamate Triquetrum

Capitate Trapezoid

Roof

Flexor retinaculum

Flexor retinaculum

Radial side

Scaphoid

Trapezium

Ulnar side

Pisiform

Hook of the hamate

Pathophysiology and Clinical Symptoms A compression neuropathy of the median nerve can be caused either by narrowing of the cross-section of the tunnel or by an increase in volume of its contents. Tenosynovitis or chronic fibrosis of the flexor-tendon sheath is found in up to 85 % of cases, usually as a result of repeated strain. Further causes are summarized in Table 46.2. Clinically, there is burning pain, numbness and paresthesia of the first to third fingers and on the radial side of the fourth finger. Pain is triggered or increased at night by inactivity during sleep and can radiate into the forearm and the shoulder. Symptoms can also be provoked by percussing the palmar side of the carpus (Tinel’s sign) and forced flexion of the wrist (flexion test). In the chronic stage, there are atrophy of the thenar muscles. Atypical clinical symptoms are not uncommon, e.g., no loss of motor function due to extremely proximal separation of the motor branch for the thenar muscles or an atypical sensory distribution when there is proximal crossover between the median nerve and the ulnar nerve. Electroneurography (ENG) and electromyography (EMG) usually show decreased nerve-conduction velocity and lengthening of the motor and sensory nerve latency.

Table 46.2 Most important causes of carpal tunnel syndrome Thickened flexortendon sheaths Tumors

U U

U

U

Crystal deposition arthropathies

U

U U

Congenital abnormalities

U

U U

Osseous carpal stenosis

U U

U

Venostasis and edema

U U U

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Tenosynovitis Chronic fibrosis Ganglion cyst, lipoma, hemangioma Neurogenic tumors Calcium hydroxyapatite osteoarthropathy (acute calcium deposit disease) Gouty arthritis Amyloidosis (usually hemodialysis patients) Bellies of the flexor digitorum muscles that extend distally Accessory muscles Persisting median artery Displaced fractures Lunate and perilunate dislocations Carpal osteoarthritis (SLAC and SNAC wrist) Pregnancy, menopause Right ventricular heart failure Sequelae of fractures and contusions

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46 Carpal Tunnel Syndrome

Diagnostic Imaging Radiography Radiography of the wrist and the carpal tunnel can provide evidence of an osseous carpal stenosis resulting from fractures, dislocations, or degenerative or inflammatory processes. Soft-tissue calcifications, as in acute hydroxyapatite deposition disease (Fig. 46.3), can also be identified.

Ultrasonography The median nerve can best be identified on axial scans. The tendons of the flexor pollicis longus muscle and the flexor digitorum superficialis tendon of the index finger can be localized by moving the fingers. The nerve usually lies immediately palmar of these structures (see Figs.

a

b

c

d

e

f

7.3–7.5). The tendon of the palmaris longus muscle, which is superficial to the flexor retinaculum just above the median nerve, can also serve as a guiding structure. The echogenicity of the nerve depends on the acoustic angle, but is always somewhat less than that of the tendons. The three characteristic findings in the carpal tunnel syndrome, which can occur in isolation or in combination, are listed in Table 46.3 (Fig. 46.2 d–f). The US findings can be quantified. The cross-sectional area A and the flattening ratio R of the nerve, as well as the palmar deviation PD of the flexor retinaculum serve as measuring parameters. The definitions of these parameters and their normal values can be found in Table 46.4.

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Fig. 46.2 a–f Imaging findings in the carpal tunnel syndrome. a T2-weighted FSE sequence at the level of the distal radioulnar joint. Median nerve (arrow) with normal shape and signal intensity. b In the same sequence at the level of the pisiform, the median nerve (arrow) is flattened and has an increased signal intensity. The transverse carpal ligament bulges considerably in a palmar direction. c Also at the level of the hook of the hamate, the median nerve (arrow) is flattened and has increased signal intensity. d Transverse US scan at the level of the pisiform. The median nerve (arrow) is flattened, and the transverse carpal ligament bulges considerably in the palmar direction. e US cross-section through the distal part of the carpal tunnel. Distinct flattening of the median nerve (arrow). f Sagittal US scan through the carpal tunnel. The distal flattening of the median nerve (arrow) is easily recognizable.

Diagnostic Imaging

Table 46.3 US findings in carpal tunnel syndrome Proximal swelling/pseudoneuroma of the median nerve: Especially in the proximal section of the carpal tunnel U Edema in early stage, later increase in endoneural and perineural connective tissue U

Distal flattening of the median nerve: More in the distal, less often in the proximal section of the carpal tunnel U Caused by compression U

Bulging of the flexor retinaculum: Toward the palmar side U As a result of increased volume of the tunnel content

Fig. 46.3 Acute carpal tunnel syndrome caused by hydroxyapatite calcium deposit disease. The radiographic carpal-tunnel view shows a homogeneous calcification within the tunnel.

U

Computed Tomography

Besides these general changes, even the pathology causing the carpal tunnel syndrome can sometimes be identified with US. U Acute tenosynovitis is easily recognizable because of fluid accumulation around the generally thickened and indistinctly contoured tendons, whereas diagnosis of discrete thickening of the tendon sheaths is more difficult. U Ganglion cysts have smooth margins and are hypoechoic or anechoic. U Atypical muscles (Fig. 46.8 b, c) can best be seen in longitudinal sections. U A persisting median artery (see Figs. 15.19 and 46.9) is associated with a proximal division of the median nerve in up to 10 % of cases and can be identified in duplex US. The advantages of US are its easy application and low costs. A disadvantage is the limited contrast resolution, which makes it difficult to identify the median nerve in the distal section of the tunnel and when it lies between the flexor tendons. Mild degrees of compression can be overlooked as a result of inherent errors in measurement.

In carpal tunnel syndrome, CT can only inconsistently demonstrate the widened tendon sheaths of the finger flexors and the thickened flexor retinaculum. Therefore, CT is usually not indicated for evaluation of the carpal tunnel. CT is only useful in nonidiopathic (secondary) forms of carpal tunnel syndrome by providing evidence of carpal malalignment in axial cross-sections (Fig. 46.4). The extent of osseous carpal stenosis due to carpal instability or advanced osteoarthritis can be recognized better in CT imaging than in the radiographic carpal tunnel view. For quantification, the transverse distances at the entrance and the exit of the tunnel (Table 46.5) can be used. Carpal cross-sectional areas are usually overestimated in CT because of insufficient delineation of the deep boundaries of the tunnel from the layers of fatty tissue near the bones located outside the tunnel. Further indications for CT are suspicion of acute inflammatory calcium deposition diseases, which can be sensitively identified deep in the carpal tunnel, and the rare soft-tissue tumors (e.g., ganglion cyst, lipoma, fibrolipoma) in the secondary carpal tunnel syndrome. As explained below, visualization of soft-tissue lesions in the carpal canal is less effective in CT than in MRI.

Table 46.4 Normal ultrasonographic values for the median nerve and the flexor retinaculum Parameter

Definition*

Level with the DRUJ†

Level with the Pisiform

Level with the Hamate

Cross-sectional area (A) of the median nerve

A Â ¼×b × π

6–10 mm2

6–11 mm2

6–10 mm2

Flattening ratio (R) of the median nerve

R = a/b

2.0–4.0

2.0–4.0

2.2–4.2

Palmar deviation (PD) of the flexor retinaculum

Fig. 46.1 c

–

–

0–4 mm

* a = the longitudinal axis; b = the short axis of the cross-section of the nerve. † DRUJ = distal radioulnar joint.

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46 Carpal Tunnel Syndrome

Fig. 46.4 a, b Chronic osseous stenosis of the carpal tunnel following carpal fracture-dislocation and palmar dislocation of the lunate. a Axial CT scan shows the lunate dislocated in the carpal tunnel with partial cystic remodeling. b Sagittal multiplanar reconstruction shows the lunate dislocated to the palmar side.

a

b

Magnetic Resonance Imaging The normal and pathologic anatomy of the carpal tunnel and its adjacent structures can best be seen in axial T1and T2-weighted SE and FSE sequences. Coronal and sagittal slices can also be useful for evaluating anomalies of the carpal bones or space-occupying masses. The flexor retinaculum and the flexor tendons have low signal intensity in all MRI sequences. Synovial tissue, which has an intermediate signal intensity, is located between these structures. The normal median nerve has a slightly higher signal intensity in T1-weighted sequences than the tendons and displays no significant increase in intensity in T2-weighted sequences. The normal ultrasonographic values for the cross-sectional area and the flattening of the nerve also apply in MRI.

Table 46.5 Distances (in mm) at the entrance and exit of the carpal tunnel as measured in CT imaging (according to Schmitt) Measured Distance

Males

Females

Tunnel entrance: scaphoid–pisiform

36.7 ± 2.3

33.6 ± 1.9

Tunnel exit: trapezium–hamate

23.6 ± 1.8

21.4 ± 1.6

In carpal tunnel syndrome, aside from the previously described changes in the shape of the median nerve, an increase in signal intensity of the nerve on T2-weighted sequences due to edema is an additional diagnostic finding (Table 46.6, Fig. 46.2 a–c). Because of the increased signal intensity in T2-weighted sequences, tenosynovitis of the finger flexors can be seen significantly better with MRI than with US. In chronic carpal tunnel syndrome, the median nerve can also appear hypointense in T2-weighted sequences when its nerve sheath exhibits atrophy and fibrosis. Rare soft-tissue tumors causing a carpal tunnel syndrome can best be identified with MRI. Of these, ganglion cysts are the most common. These appear hypointense in T1-weighted sequences and hyperintense in T2-weighted sequences.

Table 46.6 MRI findings in carpal tunnel syndrome U U U

U U

Proximal swelling/pseudoneuroma of the median nerve Distal flattening of the nerve Increase in signal intensity of the nerve: especially in T2-weighted sequences as a result of edema caused by compression Increased palmar bulge of the flexor retinaculum Tenosynovitis of the flexor tendons: hyperintense in T2-weighted sequences because of edema or effusion

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Diagnostic Imaging

a

a

a

b

Fig. 46.5 a, b Normal findings after carpal tunnel surgery. a In the axial PD-weighted FSE sequence, the flexor retinaculum is completely transsected. The incision is marked by arrows. b In the US examination, the median nerve (enclosed by a dotted line) is immediately beneath the transsected flexor retinaculum.

b

Fig. 46.6 a, b Incomplete sectioning of the flexor retinaculum. a The axial PD-weighted FSE sequence shows an incompletely transsected flexor retinaculum at the exit of the carpal tunnel (arrows). b In the corresponding T2-weighted FSE sequence the median nerve has increased signal intensity due to edema and is flattened by compression. Fig.46.7 a, b Persisting compression of the median nerve caused by hypertrophic scar tissue after carpal tunnel surgery. a The axial PD-weighted FSE sequence at the level of the pisiform shows enclosure of the median nerve (arrow) by extensive scar tissue. b Normal shape of the median nerve (arrow) at the exit of the carpal tunnel.

b

L C P

T

b

mf

a

c

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R

Fig. 46.8 a–c Carpal tunnel syndrome due to a muscle anomaly. a In the coronal T1-weighted SE sequence, the bellies of the digital flexor muscles (mf) reach far into the carpal tunnel. T = trapezium, P = pisiform. b The sagittal US scan also shows the lengthened flexor muscles extending far into the carpal tunnel (arrows). R = radius, L = lunate, C = capitate. c The corresponding T2weighted FSE sequence shows the flattened median nerve with increased signal intensity (arrow).

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46 Carpal Tunnel Syndrome

MA

a

MN

MA MN

b

Fig. 46.9 a, b Carpal tunnel syndrome with proximal division of the median nerve and persisting median artery. a The axial US scan at the level of the pisiform shows a bifid median nerve (N1 and N2) with a median artery (MA) interposed between the two nerv branches. b US scan through the distal carpal tunnel with flattened and bifid median nerve (MN) and a small interposed median artery in the middle (MA).

Postsurgical Findings Diagnostic imaging provides the following clinical information for assessment of unresponsive or recurrent complaints after the flexor retinaculum has been transsected: U Complete interruption in the continuity of the flexor retinaculum with a normally formed median nerve excludes persisting compression (Fig. 46.5). U The most common cause of therapeutic failure is incomplete transsection of the flexor retinaculum in about 60 % of cases. MRI often reveals intact ligamentary components in the distal section (Fig. 46.6), whereas US evidence is often uncertain. U Abnormal flattening of the median nerve in US or MRI indicates persisting compression. The nerve remains

U

U

U

swollen in about 70 % of cases even after successful surgery (Figs. 46.7, 46.8). Unchanged high signal intensity of the nerve in T2weighted sequences with simultaneous flattening indicates edema caused by compression. If the shape of the median nerve is normal, this can be caused by persisting neuritis. Persisting nerve compression by excessive scar tissue can also be visualized better with MRI (Fig. 46.7). In some cases, a postsurgical weakness of grip can be explained by a massive palmar prolapse of the flexor tendons.

Therapeutic Options Surgical treatment of carpal tunnel syndrome consists of decompression of the median nerve by transsectioning of the flexor retinaculum. Aside from the conventional method of open transsection with a direct view of the nerve, endoscopic transsection of the roof of the carpal canal can be achieved in the single- and dual-port tech-

nique. After the entrance to the carpal tunnel is located, an endoscope is advanced and the flexor retinaculum is split under direct endoscopic guidance. Complete transsection of the flexor retinaculum is decisive for therapeutic success.

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Therapeutic Options

Further Reading Allmann KH, Horch R, Uhl M, Gufler H, Altehoefer C, Stark GB, Langer M. MR imaging of the carpal tunnel. Eur J Radiol. 1997;25: 141–145. Bak L, Bak S, Gaster P et al. MR imaging of the wrist in carpal tunnel syndrome. Acta Radiologica. 1997;38:1050–1052. Brahme SK, Hodler J, Braun RM, Sebrechts C, Jackson W, Resnick D. Dynamic MR imaging of carpal tunnel syndrome. Skeletal Radiol. 1997;26:482–487. Buchberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: Diagnosis with high-resolution sonography. Am J Roentgenol. 1992;159:793–798. Buchberger W, Judmaier W, Birbamer G. The role of sonography and MR tomography in the diagnosis and therapeutic control of the carpal tunnel syndrome. Fortschr Röntgenstr. 1993;159:138–143. Buchberger W. Radiologic imaging of the carpal tunnel. Eur J Radiol. 1997;25:112–117. Chen P, Maklad N, Redwine M, Zelitt D. Dynamic high-resolution sonography of the carpal tunnel. Am J Roentgenol. 1997;168: 533–537. Chen CK, Chung CB, Yeh L et al. Carpal tunnel syndrome caused by tophaceous gout. CT and MR imaging features in 20 patients. Am J Roentgenol. 2000;175:655–659. Cooney WP. Vascular and neurologic anatomy of the wrist. In: Cooney WP III, Linscheid RL, Dobyns JH, eds. The Wrist: Diagnosis and Operative Treatment. St. Louis: Mosby; 1998:106–123. Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. Am J Roentgenol. 1999;173:681–684. Farooki S, Ashman CJ, Yu JS, Abduljalil A, Chakeres D. In vivo highresolution MR imaging of the carpal tunnel at 8.0 tesla. Skeletal Radiol. 2002;31:445–450. Hunt TR, Osterman AL. Complications of the treatment of carpal tunnel syndrome. Hand Clin. 1994;10:63–71. Ikeda K, Haughton VM, Ho KC, Nowicki BH. Correlative MR anatomy of the median nerve. Am J Roentgenol. 1996;167:1233–1236. Jarvik JG, Kliot M, Maravilla KR. MR nerve imaging of the hand and wrist. Hand Clin. 2000;16:13–24. Jessurun W, Hillen B, Hufstadt AJC. Carpal tunnel release: Postoperative care. Handchir Mikrochir Plast Chir. 1988;20:30–40. Keir PJ, Wells R. Changes in geometry of finger flexor tendons in the carpal tunnel with wrist posture and tendon load: An MRI study on normal wrists. Clin Biomechan. 1999;14:635–645. Kleindienst A, Hamm B, Hildebrandt G, Klug N. Diagnosis and staging of carpal tunnel syndrome: Comparison of magnetic resonance imaging and intraoperative findings. Acta Neurochir. 1996;138: 228–233. Langloh ND, Linscheid RL. Recurrent and unrelieved carpal tunnel syndrome. Clin Orthop. 1972;83:41–47. Lee D, van Holsbeeck MT, Janevski PK, Ganos DL, Ditmars DM, Darian VB. Diagnosis of carpal tunnel syndrome. Ultrasound versus electromyography. Radiol Clin North Am. 1999;37:859–872. Leonard L, Rangan A, Doyle G, Taylor G. Carpal tunnel syndrome—is high-frequency ultrasound a useful diagnostic tool? J Hand Surg. 2003;28:77–79. Luyendijk W. The carpal tunnel syndrome: The role of a persistent median artery. Acta Neurol. 1986;79:52–54. Lynch AC, Liscomb PR. The carpal tunnel syndrome and Colles’ fracture. J Am Med Assoc. 1963;185:363–366.

MacDonald RI, Lichtman DM, Hanlon JJ, Wilson JN. Complications of surgical release for carpal tunnel syndrome. J Hand Surg Am. 1978; 3:70–76. Martinoli C, Bianchi S, Gandolfo N, Valle M, Simonetti S, Derchi L. US of nerve entrapment in osteofibrous tunnels of the upper and lower limb. Radiographics. 2000;20:199–217. Martinoli C, Schenone A, Bianchi S et al. Sonography of the median nerve in Charcot-Mari-Tooth disease. Am J Roentgenol. 2002;178: 1553–1556. Mesgarzadeh M, Schneck CD, Bonakdarpour A et al. Carpal tunnel: MR Imaging. Part I. Normal anatomy. Radiology. 1989;171: 743–748. Mesgarzadeh M, Schneck CD, Bonakdarpour A, Mitra A, Conaway D. Carpal tunnel: MR imaging. Part II. Carpal tunnel syndrome. Radiology. 1989;171:749–754. Middleton WD, Kneeland JB, Kellman GM et al. MR imaging of the carpal tunnel: Normal anatomy and preliminary findings in the carpal tunnel syndrome. Am J Roentgenol. 1987;148:307–316. Murphy RX Jr, Chernofsky MA, Osborne MA, Wolson AH. Magnetic resonance imaging in the evaluation of persistent carpal tunnel syndrome. J Hand Surg. 1993;18A:113–120. Nakamichi K, Tachibana S. Ultrasonographic measurement of median nerve cross-sectional area in idiopathic carpal tunnel syndrome: Diagnostic accuracy. Muscle & Nerve. 2002;26:798–803. Paley D, McMurtry RY. Median nerve compression by palmarly displaced fragments of the distal radius. Clin Orthop. 1987;215: 139–147. Phalen GS. The carpal tunnel syndrome: Clinical evaluation of 598 hands. Clin Orthop. 1972;83:29–40. Radack DM, Schweitzer ME, Taras J. Carpal tunnel syndrome: are the MR findings a result of population selection bias? Am J Roentgenol. 1997;169:1649–1653. Richman JA, Gelberman RH, Rydevik BL, Gylys-Morin VM, Hajek PC, Sartoris DJ. Carpal tunnel volume determination by magnetic resonance imaging three-dimensional reconstruction. J Hand Surg. 1987;12A:712–717. Roy B, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: A critical review of the literature. Muscle & Nerve. 2003; 27:26–33. Sarria L, Cabada T, Cozcolluela R, Berganza TM, Garcia S. Carpal tunnel syndrome: Usefulness of sonography. Eur Radiol. 2000;10: 1920–1925. Schmitt R, Lucas D, Buhmann S, Lanz U, Schindler G. Computed tomographic findings in carpal tunnel syndrome. Fortschr Röntgenstr. 1988;149:280–285. Skie M, Zeiss J, Ebraheim NA, Jackson WT. Carpal tunnel changes and median nerve compression during wrist flexion and extension seen by magnetic resonance imaging. J Hand Surg. 1990;15A: 934–939. Sugimoto H, Miyayi N, Ohsawa T. Carpal tunnel syndrome: Evaluation of median nerve circulation with dynamic contrast enhanced MR imaging. Radiology. 1994;190:459–466. Uchiyama S, Itsubo T, Yasutomi T, Nakagawa H, Kamimura M, Kato H. Quantitative MRI of the wrist and nerve conduction studies in patients with idiopathic carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 2005;76:1103–1108.

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Ulnar Tunnel Syndrome (Guyon’s Canal Syndrome) R. Schmitt, P. Hahn

Guyon’s canal is, after the sulcus of the ulnar nerve in the elbow, the second most likely location for compression neuropathy of the ulnar nerve. Anatomic variations of the nerve and the fibrous tendinous arch within the canal often escape detection in diagnostic

imaging, but macroscopic causes of damage to the ulnar nerve, like ganglion cysts, scar tissue, and tumors of the nerve sheath, can be identified with imaging techniques.

Preliminary Remarks on Anatomy The ulnar tunnel (Guyon’s canal) is located in a mediopalmar position relatively to the carpal tunnel and contains the ulnar artery and nerve (Fig. 47.1). The 1.5-cmlong osteofibrous canal begins at the level of the pisiform and ends at the hook of the hamate. It is bordered by the anatomic structures listed in Table 47.1. The palmar branch of the ulnar nerve divides into its superficial and deep branches immediately in front of or in the proximal section of the canal. At the canal exit, the deep nerve branch passes through a narrow area between the hook of the hamate and a fibrous tendinous arch, which serves as the origin of the flexor digiti minimi brevis muscle. At this height, the superficial branch of the nerve passes through the canal in radiopalmar direction. Generally, the nerve and its branches are located on the ulnar side of the ulnar artery. There can be variations in the branches.

a

pcl vcl

fr

un

b

fr fr spb svb

pcl vcl

dpb dvb

fa fdmbm phl

Table 47.1 Anatomic boundaries of Guyon’s canal Boundary

Anatomic Structure

Floor

U U

Roof

U U

Ulnar side

U U

Radial side

U U

Flexor retinaculum Pisohamate ligament Palmar carpal ligament Fascia of the palmaris brevis muscle in some cases Pisiform Flexor digiti minimi brevis muscle Palmar aponeurosis Hook of the hamate

Fig. 47.1 a, b Diagram of cross-sectional anatomy of Guyon’s canal. a Cross-section at the level of the pisiform with visualization of the palmar branch of the ulnar nerve (un). b Cross-section at the level of the hook of the hamate after division of the ulnar nerve into the superficial palmar branch (spb) and the deep palmar branch (dpb). Other abbreviations: fr= flexor retinaculum; pcl = palmar carpal ligament; phl = pisohamate ligament; fa = fibrous arch; fdmbm = flexor digiti minimi brevis muscle.

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Diagnostic Imaging

Pathoanatomy and Clinical Symptoms The causes listed in Table 47.2 can be responsible for the damage of the ulnar nerve. Isolated or combined neural deficits can occur in sensible function of the ring and

little fingers and in the motor function of the hypothenar and intrinsic musculature, depending on the site of damage within Guyon’s canal.

Diagnostic Imaging Radiography

Computed Tomography

Fractures, nonunions, osteoarthritic changes, and osteodestructive processes on the ulnar side of the wrist can be identified in survey and special radiographs (carpal tunnel view, semisupinated oblique view of the pisiform). Soft-tissue lesions, with the exception of acute hydroxyapatite deposits, generally escape radiographic detection.

CT is the method of choice for the identification of fractures and nonunions of the hook of the hamate (see Fig. 21.10). This type of injury, which is seen more often than expected in everyday clinical routine, should always be taken into consideration when there is a peripheral injury of the ulnar nerve. The branches of the ulnar nerve can be directly injured by fragments of the hook after a trauma or compressed by paraosseous scar tissue (Fig. 47.2). Normally, the ulnar nerve can be visualized up to its division in CT, but after a trauma this is no longer possible because of nerve encasement in scar tissue. The same masking can occur around the ulnar neurovascular bundle in case of inflammatory infiltrates of an acute calcium deposit. The fibrous tendinous arch that passes over the deep branch of the ulnar nerve at the tunnel exit can be seen in CT only if it is thicker than the normal 2 mm. The most important soft-tissue tumors or lesions located in Guyon’s canal display the diagnostic criteria listed in Table 47.3.

Ultrasonography The domain of high-resolution US is the detection of ganglion cysts, which can originate from the pisotriquetral and hamatotriquetral joints or from the tendon sheath of the flexor carpi ulnaris muscle. The diagnostic criterion is an anechoic, delineated space-occupying lesion with a capsule-like margin and distal acoustic enhancement. Other lesions that can easily be recognized in US are aneurysms of the ulnar artery and hypoechoic tumors, which include neurinomas, neurofibromas, and posttraumatic neuromas of the ulnar nerve (Fig. 47.3). US evaluation is limited by acoustic shadowing artifacts at the osteoligamentary structures of the canal.

Table 47.2 Most common causes of the ulnar tunnel syndrome Acute neural trauma

U U U

Chronic neural trauma Inflammations

U U

U U

Intra-/perineural scars Anatomic variants Tumors

U U

U U

U U U

Direct blow (neurapraxia) Cut wound Carpal fractures/fracture-dislocations Long-term use of walking aids, screwing devices, bicycle handlebars Hypertrophic callus formation or nonunion of the hook of the hamate Acute hydroxyapatite deposition disease Gouty arthritis After carpal trauma After surgery Thickening of the fibrous tendinous arch Atypical course of the abductor digiti minimi muscle Usually ganglion cyst Rarely lipoma, intraneural fibrolipoma, schwannoma Posttraumatic neuroma, hemangioma, aneurysm or thrombosis of the ulnar artery, soft-tissue sarcoma

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47 Ulnar Tunnel Syndrome (Guyon’s Canal Syndrome)

U P

Fig. 47.2 CT evidence of perineural scar tissue in Guyon’s canal. A 27-year-old man with pain on the ulnar side three months after a fall on the extended hand. A focal tissue proliferation at the top and on the ulnar side of the hook of the hamate (arrows) is seen in the soft-tissue window of an axial CT scan. The deep branch of the ulnar nerve is masked.

Fig. 47.3 US of a posttraumatic neuroma of the ulnar nerve. Sagittal longitudinal scan through Guyon’s canal. Four months after deep injury with a glass splinter, there is a hypoechoic space-occupying lesion (arrow) near the pisiform (P). From the left side the palmar branch of the ulnar nerve extends into the lesion. Location of a trigger point by palpation under ultrasonic guidance.

Magnetic Resonance Imaging

the ulnar nerve, which only has an intermediate signal intensity. Ganglion cysts usually arise from the pisotriquetral joint. They often displace and expand the deep branch of the ulnar nerve in a bow. Pseudoneuroma-like thickening and increase in signal intensity in the nerve have not been observed in ulnar tunnel syndrome, which may be explained by the limited resolution of MRI in this field. Table 47.3 summarizes the signal characteristics of the most important soft-tissue tumors in Guyon’s canal.

Because of its superior soft-tissue contrast and multiplanar capabilities, MRI is the preferred diagnostic procedure in evaluation of the ulnar tunnel syndrome. Anatomic variants, such as an accessory abductor digiti minimi muscle (see Fig.15.16), can be clearly visualized by means of MRI. Ganglion cysts in Guyon’s canal are recognizable by the high signal intensity in T2-weighted sequences (Fig. 47.4), and they can be differentiated from

Table 47.3 Imaging characteristics of soft-tissue masses in Guyon’s canal Entity

US

Ganglion cyst

U

Neurinoma and neurofibroma

CT

U

Anechoic Distal acoustic enhancement

U

Hypoechoic

U U

U

Smooth borders Density: 15–35 HU Strong contrast enhancement

MRI U U

U

U

Soft-tissue sarcoma

U

Difficult to visualize

U U

False aneurysm

U U

Pulsating Doppler flow signal

U

Capsule-like border Or diffuse infiltration Strong contrast enhancement

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U U

U U

Smooth borders Hyperintense in T2weighted sequences Hyperintense in T2weighted sequences Strong contrast enhancement Capsule-like border Or diffuse infiltration Flow void Strong contrast enhancement

Therapeutic Options

G P a

Fig. 47.4 a, b MRI of a ganglion cyst in Guyon’s canal. a The axial T2*-weighted GRE sequence shows a 13 mm hyperintense space-occupying lesion partially divided by septa located in the distal section of Guyon’s canal. b In the sagittal scan, the deep branch of the ulnar nerve (arrow) is displaced far to the palmar side and arched. Fatsaturated T1-weighted SE sequence after administration of gadolinium. P = pisiform; G = ganglion cyst.

b

Therapeutic Options Surgical treatment of Guyon’s canal syndrome consists of opening the canal and inspecting the ulnar nerve. Special care must be taken to visualize the motor branch separately, since its site of origin can be narrowed. This treatment is carried out in an open surgical procedure. An endoscopic procedure should not be carried out in Guyon’s canal syndrome because of the increased danger of injuries to the ulnar vessels and nerve.

Further Reading Barberie JE, Connell DG, Munk PL, Janzen DL. Ulnar nerve injuries of the hand producing intrinsic muscle denervation on magnetic resonance imaging. Austral Radiol. 1999:43:355–357. Berkowitz AR, Melone CP, Belsky MR. Pisiform-hamate coalition with ulnar neuropathy. J Hand Surg. 1992;17A:657–662. Bordalo-Rodrigues M, Amin P, Rosenberg ZS. MR imaging of common entrapment neuropathies at the wrist. Magn Reson Imaging Clin N Am. 2004;12:265–279. Dellon LA, Mackinnon SE. Anatomic investigations of nerves at the wrist: II. Incidence of fibrous arch overlaying motor branch of ulnar nerve. Ann Plast Surg. 1988;21:36–37. Drouet A, Meyer X, Crozes P. MRI studies of ulnar nerve compression at the wrist. Joint Bone Spine. 2004;71:251–252. Egawa M, Asai T. Fracture of the hook of hamate: Report of six cases and the suitability of computerized tomography. J Hand Surg. 1993;8:393–398. Grainger AJ, Campbell RSD, Stothard J. Anterior interosseous nerve syndrome: Appearance at MR imaging in 3 cases. Radiology. 1998;208:381–384.

Harvie P, Patel N, Ostlere SJ. Ulnar nerve compression at Guyon’s canal by an anomalous abductor digiti minimi muscle: The role of ultrasound in clinical diagnosis. Hand Surg. 2003;8:271–275. Mumenthaler M. Die Ulnarisparesen. Stuttgart: Thieme; 1961. Netscher D, Polsen C, Thornby J, Choi H, Udeh J. Anatomic delineation of the ulnar nerve and artery in relation to the carpal tunnel by axial magnetic resonance imaging scanning. J Hand Surg. 1996; 21A:273–276. Ogino T, Minami A, Kato H, Takahata S. Ulnar nerve neuropathy at the wrist. Handchir Mikrochir Plast Chir. 1990;22:304–308. Ruocco MJ, Walsh JJ, Jackson JP. MR imaging of ulnar nerve entrapment secondary to an anomalous wrist muscle. Skeletal Radiol. 1998;27:218–221. Sakai K, Tsutsui T, Aoi M, Sonobe H, Murakami H. Ulnar neuropathy caused by a lipoma in Guyon’s canal. Neurol Med Chir. 2000;40: 335–338. Schmidt HM. The ‘loge de Guyon’. A contribution to the clinical anatomy of the human hand. Acta Anat. 1988;131:386–391. Subin GD, Mallon WJ, Urbaniak JR. Diagnosis of ganglion in Guyon’s canal by magnetic resonance imaging. J Hand Surg. 1989;14: 640–643. Weinstein SM, Herring SA. Nerve problems and compartment syndromes in the hand, wrist, and forearm. Clin Sports Med. 1992;11: 161–188. Zeiss J, Jakab E, Khimji T, Imbriglia J. The ulnar tunnel at the wrist (Guyon’s canal): Normal MR anatomy and variants. Am J Roentgenol. 1992;158:1081–1085. Zeiss J, Jakab E. MR demonstration of an anomalous muscle in a patient with coexistent carpal and ulnar tunnel syndrome: Case report and literature summary. Clin Imaging. 1995;19:102–105.

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Vascular Diseases of the Hand and Fingers H. Rosenthal, R. Schmitt

Catheter-based angiography of the arteries in the arm and hand—an invasive procedure—is the method of choice for differentiating functional acral vasospasm of (primary) Raynaud disease from organic arteriopathies. The most common causes of (secondary) Raynaud phenomenon are peripheral vascular disease (PVD, atherosclerosis), peripheral embolism, and

Diagnostic Imaging Instrumental evaluation of disturbances in acral circulation is largely achieved with noninvasive methods such as Doppler US, occlusion plethysmography, acral volume plethysmography, and capillary microscopy. Vessels can be directly visualized noninvasively with color-coded duplex US, which can identify the patency of arterial vessels up to the digital arteries. Angiographic examina-

endangiitis obliterans. Noninvasive MR angiography is well suited for visualization of the vessels for surgical planning the extent of vascular injuries, and malformations of the arteries and veins of the arm and hand. Color-coded Doppler ultrasonography (US) can display the perfusion of a vascular area, but its survey assessment is limited.

tions are performed to visualize morphological lesions such as stenoses, aneurysms, and arteriovenous malformations. MR angiography (MRA) offers a noninvasive method that is today preferred to arterial digital subtraction angiography (DSA) for workup of several vascular diseases. This is especially true for arteriopathies between the forearm and the metacarpus. However, MRA has only limited spatial resolution in the visualization of pathologically altered digital arteries.

Disease Entities

Peripheral Vascular Disease (Atherosclerosis) Pathoanatomy and Clinical Symptoms Atherosclerosis, a degenerative systemic disease of the arteries causing stenoses and occlusions, leads frequently to occlusions of peripheral arteries in the lower extremities. In the upper extremities, clinically manifest atherosclerosis is relatively rare. The main predisposed sites for vascular occlusion and stenoses are the supraaortal arteries near their origins. Proximal stenoses and occlusions of the subclavian artery are more likely to cause vertebrobasilar than brachial symptoms.

Findings in DSA and MRA If there is clinical suspicion of a peripheral vascular occlusion in the upper extremities, depiction of the entire aortic arch should always be obtained for reliable survey assessment. A special entity of occlusive arterial disease is the subclavian-steal phenomenon, which describes a

reverse flow in one vertebral artery when there is a proximal stenosis or occlusion of the subclavian artery. Besides vertebrobasilar insufficiency, this type of occlusion can also lead to stress-induced claudication of the affected limb, which appears especially when one works with raised arms. Vascular occlusions along the further course of the axillary and brachial arteries are relatively rare. With increasing age, elongation of the vessels in the forearm (which is not considered pathologic) can develop up to the digital arteries. Peripheral vascular stenoses rarely cause symptoms, and vascular occlusions are usually well compensated by tortuous collateral vessels (Fig. 48.1). Critical circulatory conditions are often found in patients with terminal renal failure, in this case due to degenerative vascular alterations with calcification of the vessel walls. Arteriovenous shunt procedures can also be followed by peripheral vascular occlusions.

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Peripheral Embolism

Peripheral Embolism Pathoanatomy and Clinical Symptoms

Findings in DSA and MRA

Obstruction of a peripheral artery by an embolus leads to acute ischemia with a typical clinical appearance. Only about 6 % of all arterial emboli occur in the upper extremities, and usually the axillary or brachial arteries are involved. The location of the occlusion can be determined clinically and with Doppler US with relative certainty. Catheter-based angiography is generally indicated for planning therapy and revealing the source of the embolus. Diagnostic difficulties can arise in chronic recurring small emboli, which can lead to the clinical appearance of Raynaud’s phenomenon. Only emboli in large vessels should be removed surgically with embolectomy, whereas the occlusions in the peripheral arteries can be treated with radiologic interventional methods (extraction and fragmentation approaches as well as local thrombolytic therapy). The special form of peripheral vascular occlusion caused by cyroglobulinemia should also be considered in differential diagnosis.

Angiographic signs of peripheral embolism are the abrupt interruption of the contrast-filled vessel with sharp contours at the site of occlusion and the lack of collateral vessels (Figs. 48.3–48.5). The tip of the embolus in large vessels is delineated by the contrast agent and forms a dome (“dome sign”). This is more difficult to recognize in small digital arteries. The subclavian artery is the second-most-common anatomic source of emboli after the heart chambers. One must consider the different forms of the thoracic-outlet syndrome with thrombogenic alterations of the vessel walls as the source of an embolus. Angiographic imaging including the subclavian artery must be performed in the functional position (with elevation of the upper arm) in some cases (Fig. 48.2).

a

b

Fig. 48.1 Stage IV peripheral vascular disease in an 87-yearold man. Catheter-based angiography showing occlusion of the radial artery and digital arteries with only a few collaterals. Concentric stenosis of the ulnar artery.

Fig. 48.2 a, b Thoracic-outlet syndrome in a 46-year-old patient. a Unremarkable subclavian artery in digital subtraction angiography (DSA) with the arm lowered. b Severe compression of the subclavian artery in functional DSA with the arm elevated.

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U

a

Fig. 48.3 Embolic occlusion of the princeps pollicis artery. Catheter-based angiography shows only a 2 mm-long vessel stub of the subtotally occluded artery (arrow).

Fig. 48.4 Thromboembolic occlusion of the radial artery in a female with myeloproliferative syndrome. Digital subtraction angiography with complete occlusion of the radial artery at the level of the wrist. The princeps pollicis artery and the distal segment of the ulnar digitata propria III artery are also occluded. The blood supply of the hand is provided by a hypertrophic ulnar artery and the superficial palmar arch.

b Fig. 48.5 a, b MRI in posttraumatic thrombosis of the ulnar artery. a In the axial T2*-weighted GRE image of the proximal metacarpus, the ulnar artery is thickened and filled with hyperintense occlusive thrombus (arrow). b Perivasal enhancement appears after administration of gadolinium, indicating concomitant inflammation, in the T1weighted SE sequence with fat-saturation. The arterial thrombus can be seen over its entire length (arrows).

Endangiitis Obliterans (Winiwarter–Buerger Disease) Pathoanatomy and Clinical Symptoms

Findings in DSA and MRA

Endangiitis obliterans (synonym: thrombangiitis obliterans) is an inflammatory vascular disease with a predilection for the small and middle-sized arteries and veins in the extremities. Progressive ischemia of the fingers or toes develops and can lead to soft-tissue necrosis in some cases. The upper extremities are more often affected. The symptoms are usually bilateral, although unilateral involvement has been observed. Men between 20 and 40 years of age are most commonly affected. The etiology is unclear, but nicotine abuse certainly plays a key role in the pathogenesis.

Endangiitis obliterans rarely affects the proximal arteries. For diagnostic evaluation, angiography of the brachial artery is sufficient. In catheter-based arteriography, functional pharmacoangiography should be performed using intra-arterially administered vasodilators such as acetylcholine chloride or glycerol trinitrate. MR angiography is of only limited diagnostic value in the assessment of the digital arteries because of its limited spatial and temporal resolution. Classification of endangiitis obliterans can be reliably achieved in advanced stages because of a characteristic pattern of vascular occlusion with a bizarre net-

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Raynaud Disease

work of collateral vessels. In contrast to other diseases, the corkscrew-shaped collaterals develop in the direct course of the occluded vessel (Fig. 48.6, Table 48.1). Angiographic differential diagnosis is challenging in early stages of endangiitis obliterans. Differentiation from Raynaud phenomenon caused by other underlying diseases can be unsuccessful.

Table 48.1 Angiographic signs of endangiitis obliterans U

U

U

Initial stage: – Functional thready narrowing of the arteries – Delayed acral filling, which is only achieved after intraarterial administration of vasodilative substances Acute stage: – Pharmacoangiography cannot achieve vasodilatation – Segmental filiform stenoses – Peripheral vascular occlusions – Early involvement of the distal third of the ulnar artery Advanced stage: – Segmental stenoses/occlusions in the antebrachial and digital arteries – Many corkscrew-shaped collateral vessels – Loss of normal vascular anatomy, replacement by a collateral network

Raynaud Disease Pathoanatomy and Clinical Symptoms The primary form (Raynaud phenomenon) describes an episodic vasospastic disturbance in acral circulation that can be triggered by cold or emotional stress. In primary Raynaud phenomenon, there is neither gangrene nor a

Fig. 48.6 Endangiitis obliterans in a 50-year-old man. Catheter-based angiography in the advanced stage of the disease. The arteries of the forearm, hand, and fingers are affected, leading to the formation of a diffuse network of tortuous collaterals.

recognizable underlying disease entity. This disease, which is of unknown etiology, affects women between puberty and 30 years of age in 90 % of cases.

a

b

Fig. 48.7 a, b Primary Raynaud phenomenon in a 42-year-old woman. a Digital subtraction angiography (DSA) with narrowed arteries, delayed contrast flow, and only partial visualization of the peripheral vessels. b DSA control after administration of a vasodilative substance reveals no evidence of organic stenoses.

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Findings in DSA and MRA The arteries display extreme luminal narrowing with delayed arrival of the contrast agent into the vascular periphery. During pharmacoangiography, preferably with intra-arterial administration of a vasodilative substance, the vasospasm can be interrupted. This demonstrates reliable exclusion of organic vascular occlusions (Fig. 48.7). Evidence of occluded digital arteries indicates

secondary Raynaud disease. Conversely, in what appears to be primary Raynaud phenomenon, the underlying disease can become manifest as the disease progresses. Primary Raynaud phenomenon is actually only a diagnosis of exclusion. The underlying causes of secondary Raynaud disease are numerous and are listed in Chapter 62. Diagnostic differentiation of the primary form by angiographic evaluation is often impossible.

Collagenoses and Rheumatoid Arthritis Scleroderma (Progressive Systemic Sclerosis)

increased vascular tonus are observed less frequently than in scleroderma.

Pathoanatomy and Clinical Symptoms

Panarteritis Nodosa

Scleroderma, a chronic disease of the connective tissue and blood vessels, displays Raynaud disease as an early leading symptom in 80 % of cases. A disturbance in acral circulation of the hands can be the first and only symptom. The cause of this disease is unknown. Proliferation of the endothelial cells leads to an obliterative vasculopathy of the small arteries and capillaries.

Among the collagenoses, this form of systematic vasculitis with necrotizing arteritis is characterized by a typical angiographic appearance. There are microaneurysms in the palm and digital arteries (see Fig. 39.7), which are accompanied by occlusions with a few collateral vessels in the periphery caused by thromboembolic dissemination. The hands are rarely affected.

Findings in DSA and MRA The angiographic correlate is determined by a generalized luminal narrowing of peripheral arteries, which cannot be completely reversed by vasodilative substances. Following an early stage in which differentiation from primary Raynaud phenomenon is not possible, segmental stenoses and occlusions of the digital arteries appear (Fig. 48.8). The formation of collateral vessels is incomplete. The vessels of the thumb are often not affected. In individual cases, diagnosis of the disease angiographically is possible before the appearance of typical laboratory findings and clinical characteristics.

Lupus Erythematosus Systemic lupus erythematosus is a generalized autoimmune disease of unclear origin that affects blood vessels and connective tissue. In contrast to scleroderma, Raynaud phenomenon develops in only about 20 % of affected individuals and are less obvious. Catheter-based angiography plays no decisive role in diagnosis of the disease, as angiographic findings are not pathognomonic. Occlusions of digital arteries and multiple, sometimes thready, stenoses, as well as delayed acral filling due to

Fig. 48.8 Scleroderma in a 23-year-old man. Diffuse, poorly collateralized occlusions of the digital arteries with increased tonus in the proximal vessels (catheter-based angiogram).

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Vascular Injuries and Postsurgical Angiographic Findings

Rare Vascular Diseases

Rheumatoid Arthritis

Secondary Raynaud diseases with infarction of the nail bed or even gangrene of the digits are possible symptoms of giant-cell arteritis, dermatomyositis, Wegener granulomatosis, the Churg–Strauss syndrome, and mixed collagenoses. These disease entities cannot be differentiated in arteriography because their angiographic appearance is rather unspecific. Besides functional luminal narrowing, vascular stenoses and occlusions are seen, and make the digital arteries appear fragmented. There is insufficient development of collateral vessels.

Rheumatoid arthritis, which is an inflammatory disease of the synovial tissue, often also affects the vascular system, although it exhibits few clinical symptoms. Angiographic studies have identified occlusions of digital arteries in up to 50 % of patients. In contrast to the collagenoses, however, rheumatoid arthritis is characterized by sufficient collateral vessels and, to a highly varied degree, hypervascularization around the arthritic joints.

Vascular Injuries and Postsurgical Angiographic Findings Chronic Vibration Injury Pathoanatomy and Clinical Symptoms

U U

Chronic mechanical vibrations of the hand can lead to Raynaud disease. Static stabilizing tasks, vibrations up to 800 Hz, and low temperatures are predisposing factors. Carpenters, road builders, and truck drivers are mainly affected. Arterial circulatory disorders caused by vibrations are recognized as occupational diseases by most insurers.

U

Findings in DSA and MRA Angiography reveals vascular occlusions in the carpal and digital arteries, especially in periarticular locations (Fig. 48.9). Microaneurysms and thrombotic occlusions of the arteries are also observed. Differentiation from other causes of Raynaud disease cannot reliably be achieved with angiography alone. Fig. 48.9 Arterial thrombosis in chronic vibration injury. Occlusions in both digital arteries of the middle finger (arrows). The venous phase is evident in the other fingers. Worker with long-term occupational use of a steam hammer.

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Hypothenar (Ulnar) Hammer and Thenar Hammer Syndrome Pathoanatomy and Clinical Symptoms Blunt traumas in the hypothenar region (e.g., from knocking a hub cap into place with the flat hand) can damage the ulnar artery and lead to arterial thrombosis when there is chronic exertion. The result is ischemia of the fourth and fifth fingers caused by thromboembolic occlusions of the digital arteries. The clinical appearance can resemble that of an acute arterial occlusion of the ulnar artery or insidious development of Raynaud phenomenon with deterioration when exposed to cold. The ischemic symptoms depend on the individual anatomy of the variable arteries in the palm and digits. Arterial thrombosis of the ulnar artery in the hypothenar location can also be caused by variants of muscles, such as an accessory flexor digiti minimi muscle. Less common is the disease entity referred to as the thenar hammer syndrome, in which an occlusion of the radial artery appears after repetitive blunt traumas. The

Fig. 48.10 Digital subtraction angiography of hypothenar hammer syndrome in a 42-year-old manual worker. A 5 cm-long occlusion in the distal segment of the ulnar artery in Guyon’s canal. Bridging collateral vessels have already begun to form on the ulnar side, but are still insufficient.

ischemia affects the thumb and index finger. There are indefinite transitions of pathoetiology and clinical presentations in chronic vibration injuries. Uncommon traumas can cause atypical arterial thromboses. We have seen a patient with an occlusion of the digital arteries of the middle finger at the height of the proximal interphalangeal joint after a tug-of-war with hooked middle fingers.

Findings in DSA and MRA In the hypothenar-hammer syndrome, angiography reveals an arterial thrombosis or aneurysm with thromboembolic occlusions of the digital arteries of the fourth and fifth fingers mostly at the level of the hook of the hamate (Figs. 48.10, 48.11). MR angiography is well suited for diagnostic imaging in such clinical cases and is the procedure of first choice. If the arterial palmar arch is not closed, the symptoms are particularly severe. In the thenar-hammer syndrome, the occlusion or aneurysm is projected between metacarpals I and II with thromboembolic occlusions in these two finger rays.

a

b

Fig. 48.11a, b MR angiography in hypothenar hammer syndrome. a Time-resolved MR angiogram (4 seconds per phase) shows a 1.5 cm-long occlusion of the ulnar artery with preceding stenoses. The embolic occlusions of the digitatae propriae IV arteries probably originate from the occluded ulnar artery in Guyon’s canal. b Postsurgical follow-up with MR angiography shows that the venous interposition graft is patent.

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Vascular Injuries and Postsurgical Angiographic Findings

Radiation-induced Arteriopathies Chronic radiation-induced damage of the hand has become rare nowadays (Chapter 35). Besides the generally obvious skin lesions, exposure to ionizing radiation above 2000 cGy can lead to arterial stenoses and occlusions, resulting in acral soft-tissue and osseous necroses. Radiogenic reactions in the vessel walls after radiotherapy of the axilla can cause emboli leading to disturbances in the peripheral circulation.

a vessel can lead to severe hemorrhaging with displacement and occlusion of the vessel lumen and to the formation of arteriovenous fistulas and false aneurysms. A predisposed site for false aneurysms is the ulnar artery, where chronic repetitive traumas more often cause aneurysm formation. This is closely related to the hypothenar hammer syndrome. Injury to the intimal layer can lead to complete occlusion of the vessel. Arterial walls react to contusions with vasospasms. Fractures with concomitant soft-tissue injuries can cause critical peripheral ischemia due to increased pressure in the affected compartment.

Findings in DSA and MRA

Vascular Injuries and False Aneurysms Pathoanatomy and Clinical Symptoms The arteries of the upper extremities are exposed to direct blow and indirect injuries. The gravest injury is the complete tear or severance of a vessel. Intramural tears in

A reliable sign of vascular injury is a leakage of contrast medium, which is always proof of severe, active bleeding. Arteriovenous fistulas and aneurysms also display characteristic angiographic signs (Figs. 48.12–48.14). MR angiography can be useful in combination with crosssectional imaging to depict thrombosed portions of an aneurysm. A complete occlusion can occur in a torn artery, rolled-up intima layer, or a massive vasospasm

Fig. 48.13 a, b False aneurysm of the radial artery after distal radius fracture. a Digital subtraction angiography in oblique projection shows a sacciform aneurysm of the radial artery facing the palm. b High-frequency US reveals a parietal thrombus formation in the aneurysm (asterisks).

a

radial artery radial artery*

* Fig. 48.12 Posttraumatic false aneurysm in the palm after a crush injury. Digital subtraction angiography reveals a 1.4-cm false aneurysm with a broad base to the ulnar artery and bordering on the superficial palmar arch. Narrowed digitatae communes et propriae arteries.

aneurysm

*

b

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48 Vascular Diseases of the Hand and Fingers

Fig. 48.14 Aneurysm of the ulnopalmaris pollicis artery. Contrast-enhanced high-resolution MR angiography shows a 5-mm false aneurysm, which clinically appeared as a nodule in the interdigital fold I/II.

(Fig. 48.15). An irregularity in the vessel wall is usually caused by a spasm. Narrowed antebrachial arteries over a long distance indicate a compartment syndrome.

Postsurgical Follow-up Occasionally, imaging of the vessels is indicated following surgery (Fig. 48.11 b). After replantation of a hand or finger(s), when circulation is critical, noninvasive examinations often do not provide sufficient information about arterial anastomoses. Occlusions, vasospasms, stenoses, and aneurysms can sometimes be identified in arteriograms. Despite the frequent use of the radial artery for aortocoronary bypass surgery, there have been very few indications for presurgical or postsurgical visualization of the antebrachial vessels.

Tumors of the Bones and Soft Tissues Angiography has recently lost its previous importance in the diagnostic differentiation of bone and soft-tissue tumors. Only a few tumors, such as osteoid osteomas, have a characteristic pattern of vascularization. In those cases in which it is possible to define the tumor entity,

characterization is based on the plain radiograph for bone tumors and modern cross-sectional imaging for soft-tissue tumors. Visualization of blood vessels is indicated only for surgical planning. Soft-tissue sarcomas usually have pathologic tumor vascularization.

Congenital Malformations Developmental disorders of endogenous or exogenous origin can lead to numerous malformations of the hand. The vessels are affected to different degrees. The main

indication for angiography is in planning corrective surgery, e.g., for separation of syndactylies (Fig. 48.16) or planned transfer of a toe to replace a thumb.

Fig. 48.15 Occlusion of the ulnar digitata propria artery II after a dog bite. Digital subtraction angiography reveals the occlusion of the artery in its entire length. Very fine collateral vessels with sufficient blood supply from the radial digitata propria artery.

Fig. 48.16 Arteriogram of the hand in Poland syndrome. Digital subtraction angiography for planning corrective surgery in a 1-year-old child. Hypoplasia of the radial artery, hypertrophic ulnar artery supplying the superficial palmar arch. Separate digital arteries in soft-tissue syndactyly of the middle and ring fingers.

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Arteriovenous Malformations

Arteriovenous Malformations The nomenclature of vascular malformations is manifold and confusing. Hemangiomas are differentiated from arteriovenous malformations, the latter being vascular sequel of abnormal persistence of embryonic vessels, which sometimes show a tendency to proliferate. Arteriovenous malformations of the extremities can be associated with skeletal dysplasias and growth disturbances. For differentiation of various syndromes and planning therapy, angiography in addition to plain radiography is useful in the upper extremities. The demands on the angiographic technique are especially high in all forms of arteriovenous malformation. High frame speeds are essential for optimal recording of high-flow malformations (Figs. 48.17, 48.18).

Genuine Diffuse Phlebectasia Symptoms of this disease begin unilaterally on the hand during the first years of life and progresses in a proximal direction up to middle age. Males are more often affected. Arteriovenous fistulas develop from arteriovenous anastomoses in the muscles. Skeletal lesions are not primarily present, but phleboliths can develop.

Klippel–Trénaunay Syndrome This symptom complex comprises vascular nevi, hypertrophic tissues with skeletal involvement in disproportional gigantism, and arteriovenous malformations, especially of the veins (Fig. 48.19). Active arteriovenous fistulas are not observed. The lower extremities are more often affected, and the prognosis is favorable.

Weber Arteriovenous Malformation In contrast to the Klippel-Trénaunay syndrome, Weber arteriovenous malformation has concomitant arteriovenous fistulas (Fig. 48.20). The characteristic gigantism is proportional. The vascular alterations lead to coarse, cancellous osseous remodeling. Vascular nevi are rare. The prognosis is less favorable than that of the Klippel– Trénaunay syndrome. The disease is often progressive, and necessitates surgical therapy or interventional embolization.

after 9 seconds

c

a

b

Fig. 48.17 a–c High-flow arteriovenous malformation in a 26-year-old man. interosseous artery, and both arterial palmar arches as the a An angioma as thick as a finger and a draining vein on the vascular feeders. ulnar side of the wrist fill in the early arterial DSA phase. Multiple arterial feeders. c The fat-saturated T1-weighted SE sequence after administration of gadolinium reveals the location of the angioma on the b Time-resolved MR angiography (3 seconds per phase) reveals the dorsal branch of the ulnar artery, the posterior dorsoulnar side of the carpus and metacarpus.

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Servelle–Martorell Arteriovenous Malformation This rare form of arteriovenous malformation is associated with skeletal hypoplasia. There are no arteriovenous fistulas, but vascular nevi are always present. The prognosis is doubtful.

Maffucci Syndrome In this special form of enchondromatosis, multiple enchondromas and phleboliths in the soft tissues of the hand can be seen in plain radiographs (see Fig. 44.3). Multiple hemangiomas are also seen in late-phase angiograms. a

b

Fig. 48.18 a, b Arteriovenous malformation of the index finger. a In digital subtraction angiography (DSA), the hypertrophic, corkscrew-shaped digitata propria ulnaris artery fills an angioma in the distal phalanx. Steal effect on the radial digital artery. b Corresponding findings in contrast-enhanced MR angiography. The vascular pattern is comparable, but image details are inferior to those in DSA.

Fig. 48.19 Hemangiectasia hypertrophicans (Klippel– Trénaunay syndrome). Massive hypertrophy of the index finger with ulnar clinodactyly. The ring and little fingers have already been amputated because of a tendency to hemorrhage. Catheter-based angiography shows a cavernous hemangioma in the middle finger and, to a lesser extent, also in the index finger. Early venous filling.

Fig. 48.19

Fig. 48.20

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Fig. 48.20 Weber arteriovenous malformation in a 10-year-old boy. Digital subtraction angiography shows massive hypertrophy of the antebrachial arteries and the digitatae communes et propriae arteries of the index and middle fingers with vasodilation and kinking. Early venous filling via multiple arteriovenous fistulas. Proportional gigantism.

Therapeutic Options

Therapeutic Options Revascularization is the therapeutic goal in both atherosclerosis and embolism of peripheral arteries. It can be achieved either by intravascular interventions, as in angioplasty or thrombolysis, or with bypass surgery or embolectomy. The most important procedure in endarteritis obliterans, however, is refraining from smoking. Medication consists of prostaglandin E and short-term administration of corticosteroids. If symptoms persist, sympathectomy should be considered. Treatment of arthritic diseases is discussed in Chapters 35–39. Raynaud disease and vibration traumas can be improved by calcium antagonists and nitrates. Avoidance of triggering noxa and causes is essential. Depending on the severity of complaints, a vascular interposition graft can be placed surgically at the site of occlusion in the ulnar artery in the hypothenar-hammer syndrome. Injured blood vessels generally require emergency surgical treatment. Corticosteroids and interferon are thought to impede the progression of hemangiomas. When complications arise, laser coagulation or surgical resection can become necessary. High-flow arteriovenous malformations sometimes require interventional embolization via a catheter and/or surgical resection.

Further Reading Anderson SE, De Monaco D, Buechler U et al. Imaging features of pseudoaneurysms of the hand in children and adults. Am J Roentgenol. 2003;180:659–664. Ansari A, Larson PH, Bates HD. Vascular manifestations of systemic lupus erythematosus. Angiology. 1986;37:423–432. Bauer T, Rauber K, Rau WS. Differential diagnosis of acral blood circulation disorders using intra-arterial DSA of the hand. Fortschr Röntgenstr. 1990;152:271–276. Beck A. Angiographie der Hand. Diagnostik und Therapie. Heidelberg: Springer; 1994. Brodmann M, Stark G, Aschauer M et al. Hypothenar hammer syndrome caused by posttraumatic aneurysm of the ulnar artery. Wien Klin Wochenschr. 2001;113:698–700. Burrows PE, Mulliken JB, Fellows KE, Strand RD. Childhood hemangiomas and vascular malformations: Angiographic differentiation. Am J Roentgenol. 1983;141:483–8. Chuang VP. Radiation-induced arteritis. Sem Roentgenol. 1994;24: 64–69. Conn J Jr. Thoracic outlet syndromes. Surg Clin North Am. 1974;54: 144–164. Dubois J, Garel L, Grignon A et al. Imaging of hemangiomas and vascular malformations in children. Acad Radiol. 1998;5:390–400. Esposito MD, Arrington JA, Blackshear MN, Murtagh FR, Silbiger ML. Thoracic outlet syndrome in a throwing athlete diagnosed with MRI and MRA. J Magn Reson Imaging. 1997;7:598–599. Hagen B, Lohse S. Clinical and radiologic aspects of Buerger’s disease. Cardiovasc Intervent Radiol. 1984;7:283–293. Heitmann C, Pelzer M, Tränkle M, Sauerbier M, Germann G. The hypothenar hammer syndrome. Unfallchirurg. 2002;105:833–836. Ho PK, Weiland AJ, McClinton MA, Wilgis EF. Aneurysms of the upper extremity. J Hand Surg. 1987;12A:39–46.

Jagenburg A, Goyen M, Hirschelmann R, Carstens JM, Kröger K. Hypothenar hammer syndrome: causes, sequelae and diagnostic aspects. Fortschr Röntgenstr. 2000;172:295–300. Jermann M, Eid K, Pfammatter T, Stahel R. Maffucci’s syndrome. Circulation. 2001;104:1693. Kim EY, Ahn JM, Yoon HK et al. Intramuscular vascular malformations of an extremity: findings on MR imaging and pathologic correlation. Skeletal Radiol. 1999;28:515–521. Kransdorf MJ, Turner-Stepahin S, Merritt WH. Magnetic resonance angiography of the hand and wrist: Evaluation of patients with severe ischemic disease. J Reconstr Microsurg. 1998;14:77–81. Krause U, Pabst T, Kenn W, Hahn D. High resolution contrast enhanced MR-angiography of the hand arteries: Preliminary experiences. Vasa. 2002;31:179–184. Krause U, Pabst T, Kenn W, Wittenberg G, Hahn D. MR angiography of the hand arteries. Angiology. 2001;52:763–772. Liskutin J, Dorffner R, Resinger M, Silberbauer K, Mostbeck G. Hypothenar hammer syndrome. Eur Radiol. 2000;10:542. Kreitner KF, Dueber C, Muller LP, Degreif J. Hypothenar hammer syndrome caused by recreational sport activities and muscle anomaly in the wrist. Cardiovasc Intervent Radiol. 1996;19:356–359. Langer M, Langer R. Radiologic aspects of the congenital arteriovenous malformations, Klippel-Trenaunay type, and ServelleMartorell type. Fortschr Röntgenstr. 1982;136:577–582. Latshaw RF, Weidner WA. Ulnar artery aneurysms: Angiographic considerations in two cases. Am J Roentgenol. 1978;131:1093–1095. Leipner N, Janson R, Kühr J. Angiomatous dysplasia (Weber type). Fortschr Röntgenstr. 1982;137:73–77. Levy JM, Joseph RB, Bodell LS, Nycamp PW, Hessel SJ. Prostaglandin E1 in hand angiography. Am J Roentgenol. 1983;141:1043–1046. Lippert H, Pabst R. Arterial Variations in Man. Munich: JF Bergmann; 1985. Malms J. Angiographie von Kopf, Hals und oberen Extremitäten. In: Schild H, ed. Angiographie - angiographische Interventionen. Stuttgart: Thieme; 1994:31–95. Mantero R, Grandis C, Auxilia E. Arteriographic findings in congenital malformations of the hand. Handchirurgie, 1983;15:71–76. Meharwal ZS, Trehan N. Functional status of the hand after radial artery harvesting: Results in 3,977 cases. Ann Thorac Surg. 2001; 72:1557–1561. Nakagawa K, Kozuka T, Akahane M et al. Radiological findings of accidental radiation injury of the fingers: A case report. Health Phys. 2001;80:67–70. Phillips GN, Gordon DH, Martin EC, Haller JD, Casarella W. The Klippel-Trenaunay syndrome: Clinical and radiological aspects. Radiology. 1978;128:429–434. Pouliadis GP, Bollinger A, Brunner U. The arteriographic appearances of the hypothenar hammer syndrome. Fortschr Röntgenstr. 1977; 127:345–348. Rak KM, Yakes WF, Ray RL et al. MR imaging of symptomatic peripheral vascular malformations. Am J Roentgenol. 1992;159:107–112. Rosch J, Porter JM. Hand angiography of Raynaud’s syndrome. Fortschr Röntgenstr. 1977;127:30–37. Rosenthal H, Majewski A, Wagner HH. Hand arteriography. Surgical indications and results. Fortschr Röntgenstr. 1987;146:51–57. Scott JT, Houtrihane DO, Doyle FH et al. Digital arteriitis in rheumatoid disease. Ann Rheum Dis. 1961;20:224–234. Taute BM, Behrmann C, Cappeller WA, Podhaisky H. Ultrasound imaging of the hypothenar hammer syndrome. Ultraschall Med. 1998; 19:220–224. Taylor MH, McFadden JA, Bolster MB, Silver RM. Ulnar artery involvement in systemic sclerosis (scleroderma). J Rheumatol. 2002;29:102–106.

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48 Vascular Diseases of the Hand and Fingers

Tesdal IK, Jaschke W, Haueisen H et al. Percutaneous transluminal angioplasty (PTA) of the arteries of the arm in brachial and cerebral ischemia. Fortschr Röntgenstr. 1991;155:363–369. Theumann NH, Bittoun J, Goettmann S, Le Viet D, Chevrot A, Drape JL. Hemangiomas of the fingers: MR imaging evaluation. Radiology. 2001;218:841–847. Vandevender DK, Daley RA. Benign and malignant vascular tumours of the upper extremity. Hand Clin. 1995;11:161–181. Wagner HH, Alexander K. Durchblutungsstörungen der Hände. Ihr Erscheinungsbild im Angiogramm. Stuttgart: Thieme; 1993. Wagner HH, Alexander K. Differential diagnostic value of the hand arteriogram in primary and secondary Raynaud’s syndrome. Fortschr Röntgenstr. 1985;142:10–18.

Wegelius U. Angiography of the hand. Clinical and postmortem examinations. Acta Radiol (Diagn). 1972;315(Suppl):1–115. Winterer JT, Ghanem N, Roth M et al. Diagnosis of the hypothenar hammer syndrome by high-resolution contrast-enhanced MR angiography. Eur Radiol. 2002;12:2457–2462. Yung BC, Loke TK, Chan YL. Angiomatosis of the hand demonstrated by contrast-enhanced magnetic resonance angiogram. Australas Radiol. 2000;44:198–200. Zimmerman NB. Occlusive vascular disorders of the upper extremity. Hand Clin. 1993;9:139–150.

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Differential Diagnostic Tables: Diseases of the Hand 49 Congenital and Acquired Alterations in Form and Structure of the Epiphyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

550

50 Congenital and Acquired Alterations in Form and Structure of the Metaphyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

551

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

552

51 Malformation Syndromes .

52 Dysplasias (Osteochondrodysplasias)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

560

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

562

53 Primary Metabolic Disorders of the Skeleton. 54 Arthritis

556

55 Acro-osteolyses .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56 Cystic Bone Inclusions .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

57 Polyostotic Bone Lesions .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

571 573

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

576

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

580

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

582

58 Lesions of the Periosteum and Cortical Bone . 59 Hyperostoses . 60 Osteopenia .

567

61 Soft-tissue Calcifications .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

62 Secondary Raynaud Phenomena

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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584 588

550

49

Congenital and Acquired Alterations in Form and Structure of the Epiphyses A. Horwitz

(Acquired and normal variants shown in parentheses)

Form/Structure

Description

Pseudoepiphyses

U

U

Ivory epiphyses (epiphyseal osteosclerosis)

U

U

Epiphyses or notches in atypical locations Often found distal on metacarpal I and on the bases of metacarpals II and V Osteosclerosis of small, normally formed epiphyses Usually distal and/or middle phalanx V

Found in U U U U U

U U U U U

Cone-shaped epiphyses

U

U

U

Cone-shaped, central protrusions of the epiphyses pointing toward the metaphyses The metaphyses have dents to fit the cone shape of the epiphyses 38 groups are known

U U U U U U U U U U

Fragmented/ deformed epiphyses

U

U

Numerous irregular epiphyseal fragments Caused by a growth disturbance or other lesions

U U U U U U

Ring-shaped epiphyses

Spotted epiphyses

U

U

Epiphyses with central radiolucency and indistinct margins Punctate calcifications

U U U

U U U

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Figure

Hand–foot–uterus syndrome Cockayne syndrome Trisomy 21 Homocystinuria (Normal variant)

16.1 a

Homocystinuria Silver–Russell syndrome Cockayne syndrome Trisomy 21 (Renal osteopathy, normal variant)

16.1 b

Achrondroplasia Acrodysostosis Beckwith–Wiedmann syndrome Chondrodysplasia punctata Cockayne syndrome Orofaciodigital syndrome Seckel syndrome Trichorhinophalangeal syndrome Sickle-cell anemia (Frostbite, after trauma or osteomyelitis, normal variant)

16.1 b

Spondyloepiphyseal dysplasia Morquio syndrome Gaucher disease Sickle-cell anemia ASPED syndrome (Avascular osteonecrosis, after trauma or infection)

16.1 c

Mucolipidoses Gangliosidoses (Rickets, hyperparathyroidism, hypothyroidism, scurvy) Conradi–Hünermann syndrome Zellweger syndrome Warfarin/coumarin embryopathy

551

50

Congenital and Acquired Alterations in Form and Structure of the Metaphyses A. Horwitz

(Normal variants shown in parentheses)

Form/Structure

Description

Cup-shaped metaphyses

U

U

Found in

Cup-shaped metaphyseal growth plate Lateral protrusions

U

Achrondrogenesis II Menkes syndrome Enchondromatosis Metaphyseal chondrodysplasias Mucolipidoses Shwachman syndrome Trichorhinophalangeal syndrome Wilson disease Hypophosphatasia Rickets Fluorosis

U

(Normal variants)

U U U U U U U U U U

Mushroom-shaped metaphyses Fragmented metaphyses with protrusions

U

U

U U

Wavy metaphyseal end plate

U

U

Convex bulging metaphyseal growth plate Fragmented or asymmetrically deformed metaphyses Corner sign Basket-handle fracture Growth plate usually with irregular lateral configuration Partially osteosclerotic

U U U

U U U U

Indistinct metaphyseal end plate, with some spotty densities

U

Osteosclerotic, punctate islands

U U U U U

Horizontal lines of increased density

U

Osteosclerotic metaphyseal growth plates with irregular edges

U U U U U

Horizontal radiolucent lines

U U

Band-shaped radiolucent lines Proximal of the metaphyseal end plate

U

U U U

Horizontal lines of increased density and radiolucency Vertical lines of density

U

U

Dense zones between the metaphyseal end plate and the proximal radiolucent band Longitudinal density lines in the metaphyses

U U U

U U U U

Figure U

16.1 b

Birth trauma Battered-child syndrome Scurvy Metaphyseal dysostosis Homocystinuria Rubella embryopathy Posttraumatic Metaphyseal dysostosis Hypophosphatasia Osteopoikilosis Rickets Hyperparathyroidism Homocystinuria Growth retardation Hypothyroidism Heavy-metal poisoning (Normal variant) Consuming diseases of newborns and infants Leukemia Rickets Scurvy Healing rickets Osteopetrosis Posttraumatic Osteopathia striata Rubella embryopathy Cytomegaly Posttraumatic

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U

16.28 31.6

U

41.1

U

552

51

Malformation Syndromes G. Schindler, R. Schmitt

Syndrome Acrocephalopolysyndactyly (Carpenter syndrome)

Malformation of the Hand U U U

U U

Acrocephalopolysyndactyly type I (Apert syndrome)

U

U U

U

U

Acrocephalopolysyndactyly type II (Apert–Crouzon) Acrocephalopolysyndactyly type III (Saethre–Chotzen)

Radial polydactyly Clinodactyly Syndactyly only of the soft-tissues, especially fingers III/IV Brachymesophalangia II–V Broad thumb with brachybaso-/ telephalangia Osseous syndactyly (“spoon hand”) Brachymesophalangia II–V Symphalangia of the distal interphalangeal joints Broad thumb with brachybaso-/ telephalangia and clinodactyly Carpal synostoses

U

Like type I but without involvement of thumb and little finger Monophalangeal thumb

U

Syndactyly of the soft-tissues

U

Other Malformations U

U U U U

U

U U U

U U

U U

U U U

Acrocephalopolysyndactyly type IV (Waardenburg) Acrocephalopolysyndactyly type V (Pfeiffer) Arthrogryposis

U U

U U

U U

U

U U U U U

U

Down syndrome (trisomy 21)

U

U U U

Malformations on feet resemble those of the hands (“sock feet”) Acrobrachycephaly Synostosis of the coronal suture Hypoplasia of the middle part of the face Exophthalmos, hypertelorism Mental retardation

16.9

Face as in type I Monophalangeal big toe Acrocephaly Microcephaly Slight mental retardation

Syndactyly of the soft-tissues Distal phalanges II & III divided into two parts Malformation of proximal phalanx I Partial fusion with the distal phalanx Synostoses of the carpals Flexion and ulnar inclination of the hand Enlarged carpal angle

U U U U U

Cornelia de Lange syndrome

Figure

Syndactyly and polydactyly of the feet Obesity Acrocephaly Hypophrenia Hypogonadism

Hypoplastic thumbs Brachymetacarpia I & V Brachymeso-/telephalangia II–V Clinodactyly V Kirner deformity of the distal phalanx Monodactyly or aphalangia Brachymesophalangia V with clinodactyly Syndactyly Enlarged carpal angle Four-finger crease

U U U U U U

U U U U U U U

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Synostoses of the tarsals Hip dislocation and coxa valga/vara Stiffened joints Hypoplasia of the muscles Vertical talus, clubfoot Syndactyly of the toes Micromelia, phocomelia Micrognathia Dwarfism Hirsutism Mental retardation Hypoplastic clavicle Projecting wing of ilium Blunt acetabulum angle Heart defects (ASD, VSD) Muscular hypertonus Hypertelorism Mental retardation

16.20

Malformation Syndromes

Syndrome Edward syndrome (trisomy 18)

Malformation of the Hand U

U U U U

Fanconi anemia (thrombocytopenia, aplastic-radius syndrome

U

U

U

U

U

Freeman–Sheldon syndrome (craniocarpotarsal dystrophy)

U U U

Brachymesophalangia V with clinodactyly Ulnar clinodactylies III–V Hypoplastic thumbs Radial clubhand Four-finger crease Hypoplasia or agenesis of the radius Missing, hypoplastic, or multiple thumbs Hypoplasia or agenesis of metacarpal I Brachymesophalangia V with clinodactyly Syndactyly No bony malformations Flexion contracture of the thumb Ulnar inclination of the fingers

Other Malformations U U U U U U

U U U U

U U

U

U U

Goltz syndrome (focal dermal hypoplasia)

U U

U U U

Hanhart syndrome

U

U

Hand–foot–uterus syndrome

U U

U U

Holt–Oram syndrome (heart-hand, cardiac-limb, or atriodigital syndrome)

U U

U

U

U

Klippel–Trénaunay syndrome

U

U

Langer–Giedion syndrome (trichorhinophalangeal syndrome)

U

U

Cleft hand Syndactyly, especially of fingers III/IV Adactyly Clinodactyly Camptodactyly Peromelia of the upper extremities (or all four limbs) Diverse transverse defects Hypoplastic thumbs Brachymesophalangia and clinodactyly V Pseudoepiphyses Carpal synostoses Radial clubhand Hypo-/aplastic or triphalangeal thumb Brachymesophalangia V with clinodactyly Hypoplasia/aplasia of the radial carpal bones Long ulnar styloid process Macrodactyly (soft-tissues and bones) Syndactyly Cone-shaped epiphyses on the middle phalanges of the fingers Brachymetacarpia

U U U U U U

U U

U U U U

U

U

U U U

U

U U U

Larsen syndrome

U

U U U

Brachytelephalangia with broad phalanges Brachymetacarpia Clinodactyly Radial or ulnar clubhands

U

U U

Figure

Foot deformities Hypoplastic ribs Micrognathia Heart defects (VSD, PDA) Renal malformations Delayed skeletal maturity Pes planus Syndactylies of the toes Malformed ribs and thoracic spine Hypoplastic genitals and urinary tract Pancytopenia Delayed skeletal maturity

Flat, rigid face with bulging lips (“whistling face”) Talipes equinovarus Delayed skeletal maturity Microcephaly Cleft foot Atrophic skin with poikilodermia Dystrophic nails Dysplastic teeth Colobomas Micrognathia Microstomia Small feet Short big toe Tarsal synostoses Duplications in the female genital tract Malformation of the shoulder girdle Heart defects (ASD, VSD)

Unilateral increase in size Hemangiomas, varicose veins Nevi

48.17

Cone-shaped epiphyses on the toes Pear-shaped nose Sparse hair Brachymetatarsia

16.1 b

Congenital dislocations of hips, knees, ankles, and elbows Accessory tarsals Bifid calcaneus

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553

554

51 Malformation Syndromes

Syndrome Laurence–Moon–Bardet–Biedl syndrome

Malformation of the Hand U U U U U

Marfan syndrome

U U U

Ulnar polydactyly Brachymetacarpia Brachytelephalangia Occasional syndactyly Clinodactyly Arachnodactyly Clinodactyly Slender tubular bones with thin compact bone

Other Malformations U U U U

U U U U U

Meckel syndrome (dysencephalia splanchnocystica)

U U

Ulnar polydactyly Syndactyly

U U U U U

Möbius syndrome (congenital facial diplegia)

U U U U

Mohr syndrome (orofaciodigital syndrome II)

U U U

Aplasia of a hand or fingers Polydactyly Syndactyly Brachydactyly Brachydactyly Ulnar polydactyly Syndactyly, clinodactyly

U U U U

U U U U

Myositis ossificans progressiva

U U U

Oculodento-digital syndrome

U U U

Hypoplastic thumbs Brachymetacarpia I Brachymesophalangia and clinodactyly V Bilateral syndactyly Camptodactyly IV/V Clinodactyly V

U U

U

U U U U

Papillon-Léage and Psaume syndrome (Gorlin syndrome, orofaciodigital syndrome I)

U U U U

Brachydactyly Syndactyly Clinodactyly Spotty osteopenia

U U U U U

Patau syndrome (trisomy 13)

U U U U

Ulnar polydactyly Occasionally contractures Triphalangia of the broad thumb Syndactyly

U U U

U U

Poland syndrome

U

U U U

Rubinstein–Taybi syndrome

U U

U U

Unilateral hypoplasia of the forearm, hand, and fingers Hypophalangia Brachymesophalangia Syndactyly Brachytelephalangia I Widening and triangular form of the proximal phalanx I Radial clinodactyly I Ulnar clinodactyly V

U

U U U U U U U U

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Figure

Retinitis pigmentosa Obesity Hypogonadism Mental retardation High vertebrae Aortic aneurysm Valvular heart disease Myopia, ectopia of the lenses Retinal detachment Dwarfism Microcephaly Occipital encephalocele Polycystic kidneys Cheilopalatoschisis Clubfoot Hip dislocation Pareses of cranial nerves VI & VII Mental retardation Polydactyly of the big toe Cheilopalatoschisis Split, lobulated tongue Broad nose Hypoplastic big toe Progressive calcification of the transverse-striped musculature Limited range of articular motion Syndactyly of the toes Microphthalmia, microcornea Hypoplastic teeth Small nose Bulging forehead Cheilognathopalatoschisis Split, lobulated tongue Small nose Mental retardation Feet malformed like hands Cheilognathopalatoschisis Microcephaly, microphthalmia, hypotelorism Dysplastic external ear Heart defects Partial aplasia of the pectoral muscle and abnormalities of the ribs on the same side

Analogous malformation of big toe Dislocation of radius head Blunt acetabulum angle Occasionally malformed vertebrae Microcephaly High gums Mental retardation Delayed descension of testes

16.10 48.16

Malformation Syndromes

Syndrome

Malformation of the Hand

Seckel syndrome

U U U

Ivory epiphyses Brachybasophalangia Nonuniform maturation of the skeleton of the hand

Other Malformations U U

U

Silver–Russell syndrome

U U U U U

Turner syndrome

U U U U U

Asymmetric hands Brachymesophalangia V Radial clinodactyly V Kirner deformity Nonuniform maturation of hand skeleton (larger extremities mature faster) Brachymetacarpia IV (III, V) Decreased carpal angle Carpal synostoses Madelung deformity Osteoporosis

U U U U

U U U

U U

Zellweger syndrome (cerebrohepatorenal syndrome

U U

Contractures Camptodactyly V

U

U U U U

Figure

Dwarfism “Bird head” deformity in microcephaly and hypoplasia of the maxilla and mandibula Mental retardation Asymmetric feet Hemihypertrophy Prenatal dystrophy Café-au-lait spots

Brachymetatarsia IV Cubitus valgus Malformation of the urinary tract, e.g., horseshoe kidneys Gonadal dysgenesia Aortic coarctation Deformed feet (clubfoot, rocker-bottom foot) Peripatellar calcifications Renal cysts Fibrosis of the liver Dolichocephaly with lissencephaly

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16.18 a

555

556

52

Dysplasias (Osteochondrodysplasias) G. Schindler, A. Horwitz

Disease Entity

Dysplasia of the Hand

Other Dysplasias and Symptoms

Figure

Epiphyseal Dysplasias Chondrodysplasia punctata type I (Conradi–Hünermann)

U

Punctate carpal calcifications

U U

U U U U

Chondrodysplasia punctata type II (rhizomelic form) Dysostosis epiphysaria multiplex

U

U U

U

U

Short-rib polydactyly syndrome type I (Saldino-Noonan)

Punctate carpal calcifications

U U

Epiphyses small with irregular margins and flattened on ulnar side in adulthood Brachydactyly Ulnar polydactyly Syndactyly

U

U U

U U U U U U

U

Short-rib polydactyly syndrome type II (Majewski) Stickler syndrome (arthro-ophthalmopathy)

U

U

U U

Less severe malformations Punctate calcifications in the tubular bones, intervertebral joints, and anterior pelvic ring Macro-/microcephaly Flat face and nasal root Diseases of skin and hair Prognosis better than type II Severe malformations Stillbirth or earlier fatal outcome Epiphyseal dysostoses of all tubular bones Flattened thoracic vertebrae Kyphosis of thoracic spine Small thorax Prominent abdomen Fetal hydrops Short extremities Widened intervertebral spaces Small pelvic skeleton, blunt acetabular angle Polydactyly of the feet

Irregular margins of metaphyseal end plates Ulnar and radial polydactyly Flattened epiphyses Narrowed interphalangeal joint spaces

U

U U

U

Flattened epiphyses and arthropathy of large joints Marfanoid appearance Micrognathia and gnathopalatoschisis Hypertelorism, severe myopia

Metaphyseal Dysplasias Achondroplasia congenita (chondrodystrophia fetalis)

U

U U

Ellis–van Creveld syndrome (chondroectodermal dysplasia)

U

U U U U

“Trident” hand caused by oblique radial or ulnar position of proximal phalanges II and IV Brachyphalangia Brachymetacarpia Generally shortened hand bones (P3 > P2 > P1) Triphalangeal thumb Ulnar polydactyly Carpal synostoses Syndactylies

U U U

U

U

U

U

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Disproportional microsomia Square pelvis Decreased interpeduncular spaces in lumbar spine, kyphosis Macrocephalia, prominent forehead, saddle nose Dwarfism due to short tubular bones Ectodermal disturbances (teeth, nails) Cardiac defect (ASD)

16.13

Dysplasias (Osteochondrodysplasias)

Disease Entity Hypochondroplasia (chondrohypoplasia)

Dysplasia of the Hand U U U

Short tubular bones in the hand Wide epi-/metaphyses Long ulnar styloid process

Other Dysplasias and Symptoms U U

U

U U

Hypophosphatasia tarda

U

U

Jeune syndrome (asphyxiating thoracic dysplasia)

U U U U

Rickets-like deformation of the wrists Late appearance of ossification centers Brachyphalangia Brachymetacarpia Cone-shaped epiphyses Occasionally ulnar hexadactyly

U

U U

U U U

U

U U

Metaphyseal chondrodysplasia type I (Jansen) type II (Schmid) type III (McKusick)

U

Rachitic lesions Angulated radial and ulnar metaphyses Brachymetacarpia Brachymesophalangia Cone-shaped epiphyses

U

Widened metaphyses

U U

U U

Metaphyseal chondrodysplasia with thymolymphopenia

U U

U U U

Disproportional microsomia Short tubular bones and femoral necks Narrow interpeduncular spaces in lumbar spine Concave vertebrae Normal skull Metaphyseal ossification defects of long tubular bones Rachitic “rosary” General growth retardation Long, narrow thorax Short ribs Square pelvis with osteophytic spurs Disproportional, short tubular bones Respiratory distress at birth Nephropathy Dwarfism Changes in form and structure of metaphyses in all long tubular bones

Decreased iliac height Missing thymus Agammaglobulinemia (Swiss type)

Primarily Spinal Dysplasias Diastrophic dwarfism

U U

U

Dyggve–Melchior–Clausen syndrome

U U U

Delta-shaped radial metaphysis Oval metacarpal I with radial clinodactyly Brachymetacarpia/-phalangia and deformities Brachymetacarpia Small, angular carpals Decreased carpal-height index

U

U U U

U

U U

Kniest syndrome

U

U

Congenital spondyloepiphyseal dysplasia

U U U

Delayed ossification of epiphyseal centers Widened metaphyses and deformed epiphyses on tubular bones of the hand Fairly normal in childhood Delayed carpal ossification Deformed epiphyses and metaphyses of radius and ulna

U U U

U U

U U U

Metatropic dwarfism

U U

Delayed bone maturation Disturbance of metaphyseal and epiphyseal ossification of the tubular bones of the hand

U U U U U

Widened metaphyses on shortened tubular bones Deformed vertebrae Thoracolumbar kyphoscoliosis Clubfoot Microsomia of the trunk with platyspondyly Hypoplastic pelvis Shortened tubular bones with irregular ossification Platyspondyly Bell-shaped thorax Cleft palate

Disproportional microsomia Flattened vertebrae with ventral ossification defects Dens axis not ossified Flat face Hypertelorism Normal skull Narrow thorax in childhood Ossification defects in vertebrae Platyspondyly Progressive kyphoscoliosis

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Figure

557

558

52 Dysplasias (Osteochondrodysplasias)

Disease Entity Progressive pseudorheumatoid chondrodysplasia

Dysplasia of the Hand U

U

Slight dysplasia and swelling of interphalangeal joints Large epiphyses

Other Dysplasias and Symptoms U

U

Figure

Slight dysplasias of hips, knees, and shoulders No bone destruction

Enchondromatoses Chronic idiopathic hyperphosphatasemia

U

U

Increasing bending of the tubular bones of the hand Cystoid inclusions

U U U U U

Dysosteosclerosis

U

U

Dense osteoscleroses on the epiphyses and metaphyses Widened metaphyses

U

U U

U

Enchondromatosis (Ollier disease) Enchondromatosis (Maffucci syndrome) Engelmann–Camurati disease (progressive diaphyseal dysplasia) Fibrous dysplasia (Jaffé–Lichtenstein disease)

U

Oval enchondromas in metaphyses of tubular bones of hand Sometimes pathologic fractures

U

See Ollier disease

U

U

U

U

U

U

U

Cystic widening of medullary space in tubular bones Carpals can also be affected Epiphyses not affected

U

See fibrous dysplasia

U

U

McCune–Albright syndrome

Diaphyseal thickening of compact bone (also of carpals)

U

U

U U

U U

Frontometaphyseal dysplasia

U

U

Juvenile idiopathic osteoporosis

U U

Long metacarpals and phalanges (especially hypermesophalangia III, IV, & V) Ulnar clinodactyly Generalized osteoporosis Fractures

U U U U

U U U

Craniometaphyseal dysplasia

U U

Leri–Weill disease (dyschondrosteosis)

U

U U

Melnick–Needles syndrome (osteodysplasia)

U U U

Diaphyseal sclerosis in infancy Demineralized metaphyses that later become club-shaped Short forearms with Madelung deformity Decreased carpal angle Dorsal dislocation of ulna Brachytelephalangia Flat metaphyses Dense, osteosclerotic diaphyses

U

U

U U

U U U U

U

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Microsomia due to platyspondyly Bent tubular bones Large skull with thickened calvaria Diffuse osteopenia Elevated alkaline and acid phosphatase and uric acid in serum Flattened vertebrae, dorsal wedging Microsomia Neurologic symptoms in cranial nerves III, VI, & VII Spotty skin atrophy Asymmetric shortening and bending of one extremity Unilateral deformity

16.23

Combination of Ollier disease with cavernous hemangiomas

44.3

Osteoscleroses of base of skull and calvaria Gait disturbance, muscular hypotonus Long tubular bones deformed, shortened, or lengthened Premature closure of growth plates Mono- or polyostotic See fibrous dysplasia in females Also cafe-au-lait spots and premature puberty (pubertas praecox)

43.8

Coxa valga, protrusio acetabuli Flat os ilium Prominent frontal tuberosity Mandibular hypoplasia Curved tubular bones Generalized osteoporosis Fused vertebrae Hyperostoses of the skull base, calvaria, and facial skeleton Lesions of the cranial nerves Microsomia Short tibiae

Coxa valga Irregular ribs and clavicles High vertebrae Micrognathia; narrow, high forehead Exophthalmus

16.22

Dysplasias (Osteochondrodysplasias)

Disease Entity Osteogenesis imperfecta tarda (Löbstein)

Dysplasia of the Hand U U

U

Osteogenesis imperfecta congenita (Vrolik) Osteopetrosis Albers–Schönberg (marblebone disease)

U

Micromelia Osteopenia with thin compact layer Fractures with hypertrophic callus Like Löbstein (see above)

Other Dysplasias and Symptoms U U U U U

U U

U

U U

Dense osteosclerosis of hand skeleton With or without deformation Sometimes pathologic fractures

U U

U U U

Spondyloenchondrodysplasia

U U U

Short, plump hands Wavy or concave metaphyses Enchondromas in distal radius and ulna

U U

U U U

Bent tubular bones Cod-fish vertebrae Many sesamoid bones Blue sclerae, skin atrophy Dentinogenesis imperfecta Severest malformations Usually born dead Generalized thickening of bones Metaphyses with (group I) or without (group II) deformation Sandwich vertebrae Anomalies of teeth Cranial nerve lesions Microsomia Biconcave vertebrae with narrow spinal canal Widened intervertebral disk spaces Thoracic deformity Metaphyseal enchondromas, often symmetric

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Figure

559

560

53

Primary Metabolic Disorders of the Skeleton G. Schindler, A. Horwitz

Metabolic Disease

Radiographic Signs in the Hand

Clinical Symptoms

Disorders of Carbohydrate Metabolism Hurler syndrome (MPS I H)

U U

U U U U

Scheie syndrome (MPS I S, previously MPS V)

U U

U

Short plump tubular bones Pointed proximal ends of metacarpals II–V Sugar-loaf-shaped phalanges Camptodactyly Clinodactyly V Carpal ossification delayed and irregular Initially normal radiograph Later retarded ossification of carpal bones Bone cysts

U U U U U U

U U U U

U

Hunter syndrome (MPS II)

U U

Like Hurler syndrome With different degrees of expression

U U U U U U

Sanfillipo syndrome (MPS III)

U U U

Normal findings possible Camptodactyly Pointed proximal ends of metacarpals II–V

U U U U U

Morquio syndrome (MPS IV)

U U U

U

U

Brachymetacarpia Camptodactyly Pointed proximal ends of metacarpals II–V Delayed ossification of carpals and hypoplastic carpals V-shaped distal radius and ulna

U

U U U U U U

Maroteaux–Lamy syndrome (MPS VI)

U

U

Metacarpals II–V shortened with pointed proximal ends Camptodactyly

U U U U U

Sly syndrome (MPS VII)

U U

Like Hurler syndrome Slight expression

U U U

U

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Skeletal dysplasias Contractures Cloudy cornea Deafness Mental retardation Death before the age of 10 years

Manifestation in late childhood Carpal tunnel syndrome Normal intelligence Cloudy cornea in the 3rd–4th decade of life Aortic valve defect Nanosomia Dorsolumbar gibbus Hepatosplenomegaly Coarse facial features Macroglossia Mental retardation Mild skeletal dysplasia Hepatosplenomegaly Thick blond hair Oligophrenia Epilepsy Short-trunk microsomia with platyspondyly Pectus carinatum Retroflexed head Hyperextendable joints Skeletal dysplasia Pareses due to spinal lesions Normal intelligence Nanosomia Skeletal dysplasia Dolichocephalic skull Cloudy cornea, deafness Normal intelligence Dwarfism Hepatosplenomegaly Progressive deformation of thorax and spine Pulmonary complications

Figure

Primary Metabolic Disorders of the Skeleton

Metabolic Disease Winchester syndrome

Radiographic Signs in the Hand U U U

Mucolipidosis II (Leroy inclusion-cell disease)

U

U U

Severe demineralization Extremely thin compact layer Destructive arthritis of the metacarpophalangeal and interphalangeal joints Osteopenia with disintegrated compact bone, fractures, and periosteal new bone formation Hypoplastic carpals Short metacarpals

Clinical Symptoms U U U U

U

U

U U

Figure

Severe osteoporosis Dwarfism Contractures Cloudy cornea Earlier manifestation and more severe course than MPS I Coarse facial features, high forehead Hepatosplenomegaly Intercurrent respiratory infections

16.28

Disorders of Lipid Metabolism Niemann–Pick disease (sphingomyelin lipidosis)

U U

U

Gaucher disease (glucocerebroside lipidosis)

U

U

Thinned compact bone layer Erlenmeyer-flask deformity of the metacarpals Delayed bone maturation Cystic bone lesions caused by Gaucher cells Increased cancellous and calcium density in phalanges

U U U U

U U U U

Mental and physical retardation Hepatosplenomegaly Anemia Progressive blindness Hepatosplenomegaly Anemia, leukopenia Thrombocytopenia Pigmented conjunctivae

43.7

Disorders of Protein Metabolism Phenylketonuria

U

U

U U

Homocystinuria

U

U

Spicules on the radial and ulnar metaphyses Vertical lines of density on metaphyses Osteopenia Delayed skeletal maturation Capitate and hamate relatively hyperplastic, small lunate Spicules on the ulnar and radial epiphyses

U U U

U

U U U U

Fair skin and hair Blue eyes Neurologic disorders of coordination Mental retardation Osteoporosis of skeleton of trunk Arachnodactyly Mental retardation (Sub)Luxated lenses, glaucoma

Disorders of Copper Metabolism Menkes syndrome (kinky-hair syndrome)

U

U

Spurlike protrubances on the metaphyses Periosteal appositions

U U U

Nanosomia Thin, kinky hair Epilepsy

Disorders of Calcium and/or Phosphate Metabolism Hypophosphatemic rickets

U U

Osteopenia Cup-shaped metaphyses

U U U

Hypophosphatemia

U U U

Pseudohypoparathyroidism

U U U U U U U

Signs of rickets Irregular ossification Slight metaphyseal defects Brachymetacarpia I, IV, V Brachymesophalangia II, V Brachytelephalangia Cone-shaped epiphyses Curved diaphyseal radius Subperiosteal resorption Cutaneous/subcutaneous calcifications

U U U

U U U U U

Curved femurs Hyperphosphatemia Hyperphosphaturia Soft cranial vault Respiratory insufficiency Low alkaline phosphatase Short pawlike hands Round face Obesity Hypocalcemia Hyperphosphatemia

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16.29

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54

Arthritis S. Spindler-Thiele

Metabolic Disease

Radiographic Signs in the Hand

Rheumatoid arthritis (RA)

U U U

U

U

Subtype of RA: adult Still syndrome

U

Periarticular soft-tissue swelling Periarticular osteopenia Direct signs of arthritis: marginal erosions, geodes, subchondral bone destruction, mutilation, ankylosis Distribution: metacarpophalangeal and proximal interphalangeal joints, ulnar styloid process Ulnar deviation of the fingers, swan-neck and button-hole deformity Like rheumatoid arthritis

Pathogenesis and Clinical Symptoms U

U

U

U

U

U

Subtype of RA: Felty syndrome

U

Like rheumatoid arthritis

Subtype of RA: RA appearing in preexisting polyarthrosis Psoriatic arthritis

U

U

U

U

U

Reiter syndrome

U U U

U

Like rheumatoid arthritis Trapeziometacarpal, Bouchard, Heberden osteoarthritis Additional phenomena representative of arthritis

U

U

RA and pneumoconiosis

Three patterns of distribution: – transverse type – axial type – combined type Adjacent osteoproliferation and destruction Primarily lower extremities Soft-tissue swelling Rarely joint destruction, periosteal sclerosis Parasyndesmophytes

U

U U U

U

U

Reactive arthritis

U

Like Reiter syndrome

U

U

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36.2 36.3 36.4 36.5 43.2

Symmetric, seronegative polyarthritis with organ involvement (polyserositis) Leukocytosis Seropositive polyarthritis with organ involvement Leukopenia Thrombopenia

U

U

Subtype of RA: Caplan syndrome

Usually symmetric polyarthritis of unknown cause Up to 95 % RF positive, 70 % DRW4 positive Synovitis, tenosynovitis, enthesiopathies Criteria of American Rheumatism Association

Figure

RA develops in preexisting osteoarthritis of the fingers

ca. 25 % of patients with psoriasis Asymmetric Erosive polyarthritis with unilateral or bilateral sacroiliitis

37.1 37.2 37.3 37.4 37.5

Androtropic triad: – urethritis – conjunctivitis – asymmetric arthritis with sacroiliitis 80 % HLA-b27 positive

37.6

Aseptic synovitis after infectious diseases (enteritis or venereal disease) Up to 80 % HLA-B27 positive

37.7

Arthritis

Metabolic Disease

Radiographic Signs in the Hand

Enteropathic arthritis

U U

U

Primarily lower extremities Minimal unspecific direct signs of arthritis Rare characteristic manifestation in the hand

Pathogenesis and Clinical Symptoms Usually transitory oligo- and polyarthropathies More common in Whipple disease, ulcerative colitis, and Crohn disease Rare in hepatic or pancreatic diseases, carcinoid syndrome, and celiac disease

37.9

37.8

U

Up to 50 % peripheral arthritis in ankylosing spondylitis HLA-B27 positive, RF negative

U

Up to 30 % polyarthritis

U

Associated with RA

U

U

U

Ankylosing spondylitis

U U U U

Agamma globulinemia / hypogammaglobulinemia Hashimoto autoimmune thyroiditis Behçet syndrome

No specific pattern of distribution Periarticular swelling Mild osteopenia Intra-articular osseous ankylosis possible

U

Like RA Asymmetric

U

Like RA

U

U U

Direct signs of arthritis are unusual Erosive defects on the finger joints possible

U

U U

U

Familial Mediterranean fever

U U U

No typical appearance Subperiosteal osteopenia Usually no direct signs of arthritis

U U

U

Stevens–Johnson syndrome

U

No specific radiographic signs

U U

Rheumatic fever

U

U

Lupus erythematosus disseminatus (SLE)

U U U

U

Scleroderma

U U U U U

Manifestations of type I: Acute polyarthritis: soft-tissue swelling, discrete periarticular osteopenia Manifestations of type II: Jaccoud arthritis: nonerosive arthropathy, nonfixed ulnar deviation in metacarpophalangeal joints Systemic soft-tissue swelling Elastic malalignment of joints Swan-neck and button-hole deformities Rarely epiphyseal osteonecroses of the metacarpal heads Soft-tissue atrophy Acro-osteolysis Interstitial calcinosis Diffuse osteopenia Destructive polyarthritis of DIP and PIP joints as in RA in about 25 % of cases

Figure

U

U

U

U

U U

U

U

U

Oculomucocutaneous syndrome Behçet tetralogy with joint symptoms and palindromic rheumatism Associated with sacroiliitis or spondylitis Autosomal recessive Recurring peritonitis, pleuritis, and synovitis with episodes of fever Oligoarticular arthritis Erythema multiforme exsudativum Aggressive course Reactive polyarthritis in infections with β-hemolytic streptococci Carditis, endocarditis

Immune-complex vasculitis in young women Butterfly erythema, nephritis, myocarditis Up to 90 % arthralgias ANA positive

39.1

Various forms of autoimmune systemic sclerosis Up to 50 % polyarthralgias due to synovitis Later synovial fibrosis

39.3

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39.2

39.4

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54 Arthritis

Metabolic Disease

Radiographic Signs in the Hand

Poly-/dermatomyositis

U U U

Panarteritis nodosa

U U U

Wegener granulomatosis

U

Soft-tissue calcifications Soft-tissue swelling, later atrophy Rarely direct signs of arthritis Nondestructive polyarthritis Periosteal scleroses Microaneurysms of the digital arteries Usually without radiographic signs

Pathogenesis and Clinical Symptoms U

U

U U

U

U U

Sjögren syndrome

U

Like RA

U

U

Acute bacterial arthritis

U U

U

U

Gonococcal arthritis

U U

Severe soft-tissue swelling Rapid progression, osteopenia near joints Indistinctness of the subchondral bone plate Narrowing of the joint space and marginal erosions in 8–10 days Especially in the upper extremities Like acute bacterial arthritis

U U

U U

U

U

Tuberculous arthritis

U

Like bacterial arthritis Progresses in weeks to months Rare: in children spina ventosa, expansion of the small tubular bones

Syphilis (Lues)

U

Like in tuberculous arthritis

Leprous arthritis

U

U U

U

Viral forms of arthritis

U

U U

Fungal arthritis

U U

Gouty arthritis

U

U

U

Destructive-erosive polyarthritis In carpal, metacarpophalangeal and proximal interphalangeal joints Metacarpophalangeal and proximal interphalangeal joints No direct signs of arthritis Joint destruction in bacterial superinfection and AIDS arthritis resembles rheumatoid arthritis No specific appearance Can resemble tuberculous arthritis

Soft-tissue swelling without osteopenia Besides direct signs of arthritis, epiphyseal and submarginal punched-out defects Tophic joint destruction

U

U

U

U

U U

U

U U

U U U U

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Figure

Autoimmune disease with progressive muscular weakness Skin manifestation and transient arthralgias

39.6

Systemic necrotizing vasculitis Transient articular and muscle pain in 50 % of cases

39.7

Necrotizing granulomatous vasculitis Rhinitis, sinusitis, hemoptysis In up to 75 % with joint symptoms Autoimmunological sicca syndrome and RA 50 % seropositive After cuts, stabs, and bites Infections with staphylococci (70 %), streptococci Haemophilus influenzae in children Gram-negative in immune deficiency

40.2 40.3

Usually monoarticular infective arthritis Polyarthritis in sepsis The joints of the hand are involved in up to 10 % of skeletal tuberculosis

40.4

In tertiary syphilis Spread through bloodstream or directly from an adjacent focus Consider neurosyphilis, reactive arthritis, superinfection Episodic, symmetric polyarthritis In rubella, mumps, variola, hepatitis B In AIDS patients direct joint infection with HIV, herpes simplex, or herpes zoster Rare! In blastomycosis, histoplasmosis, cryptococcosis, spirotrichosis, maduro mycosis, and osseous candidosis Rarely inherited Usually secondary hyperuricemia Lesch–Nyhan syndrome in children Possible combination with Heberden arthrosis in older women

34.1 34.2 34.3

Arthritis

Metabolic Disease Chondrocalcinosis (pseudogout, CPPD deposition)

Radiographic Signs in the Hand U

U U U U

Linear and punctate calcifications in articular and fibrous cartilage and ligaments Subchondral cystic lesions No erosions Arthrotic ganglionic cysts Joint destruction and dislocations are rare

Pathogenesis and Clinical Symptoms U

U

U U

Calcium pyrophosphate dihydrate deposits Primary familial or, more often, secondary (hyperparathyroidism, hemochromatosis, Wilson disease) Crystal-induced synovitis Osteoarthritis

Figure 27.11 27.12 34.4 34.5 34.6 34.7 34.8

Hemochromatosis

U

U

U

Ochronosis

U U U

Combination of osteoarthritis and chondrocalcinosis Up to 90 % in metacarpophalangeal joints II and III Also interphalangeal In the spine and large joints Osteoarthritis of peripheral joints No direct signs of arthritis

U U

U

U

U U U

Hemophilic arthropathy (bleeder’s joints)

U U

U U U

U

Sickle-cell anemia and thalassemia

U U

U

Amyloidosis

U U

U

Multricentric reticulohistiocytosis

U

U

U U

Hypertrophic osteoarthropathy

U

U U

U U

Soft-tissue swelling Increased bone density (hemosiderin) Periarticular osteopenia Subchondral cysts Widening, fusion, and malalignment of joints Bizarre bone appositions Soft-tissue swelling Nonerosive arthritis without direct signs of arthritis Hand–foot syndrome in black children Bulky periarticular nodules Destructive arthritis without narrowing of joint space Marginal erosions, intraosseous and subchondral cystoid defects Erosions in proximal interphalangeal joints, less common on carpal and metacarpophalangeal joints Subchondral resorption without osteopenia Acro-osteolyses Mutilation years later New periosteal bone formation (solid, lamellar, or radial) On proximal and middle phalanges Obliteration of medullary spaces possible Soft-tissue swelling No direct signs of arthritis

U

U

U U U

U

U

U U

U U

U

U

U U

U

U

Abnormal iron storage Primary or secondary (e.g., alcoholic liver cirrhosis, portocaval shunt, iron substitution, chronic hemolytic anemia)

34.12

Deposits of homogentisinic acid in alcaptonuria Discoloration and degeneration of cartilage Secondary chondrocalcinosis Detritus synovitis Calcifying fibro-ostoses Recurrent hemarthrosis in hemophilia A and B Rarely with coumarin therapy or sickle-cell anemia Aggressive destruction of cartilage Joint derangement Growth disturbance Pain in bones and joints due to vascular occlusions (bone infarcts, joint effusions) Sometimes transient polyarthritis in thalassemia minor

35.4

Inherited Often secondary (collagenoses, ulcerative colitis, associated with dialysis, multiple myeloma, Waldenström disease)

35.3

Extremely rare Papulous efflorescences of the skin and mucous membranes Up to 50 % mutilating, seronegative polyarthritis Coincidence with malignomas

Primary or secondary In neoplastic or inflammatory pulmonary diseases Less common in extrathoracic processes Clubbing of fingers, hour-glass nails, thickened skin

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54 Arthritis

Metabolic Disease Osteoarthropathy caused by ionizing radiation

Radiographic Signs in the Hand U U U U U

Neurogenic arthropathy (Charcot arthropathy)

U U U

U

U

Erosive finger osteoarthritis

U

U U U

Osteopenia Stringy, cystoid cancellous bone Acro-osteolyses Spotty osteosclerosis Bone destruction in malignomas Narrowing of joint space Fragmentation Bizarre osteophytosis and osteosclerosis (hypertrophic form) Osteolyses and resorption (atrophic form) Severe malalignments Preexisting phalangeal osteoarthritis Large erosions possible No osteopenia Malalignments and ankyloses

Pathogenesis and Clinical Symptoms U U U

U

U

U

U U

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Figure

Up to 150 Gy in children Up to 400 Gy in adults Induction of growth or trophic disturbances and bone tumors

35.6

In syringomyelia (10 % upper extremities involved) Rare in tabes dorsalis, diabetes mellitus, leprosy, damage to the spinal chord, lesions of peripheral nerves

35.2

Inflammatory activation of osteoarthritis by episodic reactive synovitis More common in males See gouty arthritis in older women and rheumatoid arthritis in preexisting osteoarthritis

27.4 27.11

567

55

Acro-osteolyses R. Schmitt, S. Spindler-Thiele

Disease Entity Rheumatoid arthritis (RA)

Local Radiographic Signs U

U

Juvenile chronic arthritis (JCA)

Psoriatic arthritis

U U

U

U

Progressive systemic sclerosis (PSS)

U

U U

Poly-/dermatomyositis

U U

Vasculitis syndromes

U

U

Occasionally erosions of unguinal tuberosities Caused by rheumatic arteriopathy Erosions of unguinal tuberosities Band-shaped osteolyses

Destruction of unguinal tuberosities “Morning-star” appearance in axial type possible Palmar defects in unguinal tuberosities (rat-bite defects) Sugar-loaf configuration Interstitial calcinosis in 25 % of the cases Acro-osteolyses Combined with patchy soft-tissue calcifications Rarely erosions of unguinal tuberosities Periostitis possible (more common in lower extremities)

Further Radiographic and Clinical Findings U U U U

U U

U U U

U U U

U U U

U U U U U

Raynaud phenomena (secondary)

U

U

Atherosclerosis

U

U U

Hyperparathyroidism

U

U

Burns

U U U U

Resorption of unguinal tuberosities in long-standing disease Rarely in primary Raynaud disease Resorption of unguinal tuberosities in stage IV Soft-tissue defects in stage IV Tubular calcification of vascular walls Marginal or band-shaped resorption of the unguinal tuberosities Reversible with therapy Resorption of unguinal tuberosities Osteoporosis Ankyloses Soft-tissue calcifications

U U

U U

U

U

U U

U U

U

Figure

Periarticular soft-tissue swelling Collateral signs of arthritis Direct signs of arthritis Rheumatic factor positive in up to 95 % of cases

36.2 36.3 36.4 36.5

Radiographic signs as in RA Clinical subtypes: Adult Still, Felty, Caplan syndromes, etc.

36.6

Asymmetric polyarthritis Iliosacral joints can be involved Osteoproliferation and osteodestruction

37.2 37.3 37.4 37.5

Sclerodactyly Osteopenia Destructive polyarthritis

39.3 39.4

Muscular weakness Cutaneous lesions Destructive polyarthritis

39.6

Panarteriitis nodosa Churg–Strauss angiitis Hypersensitivity forms of angiitis Wegener granulomatosis Takayashu arteritis

39.7

Acral ischemias Soft-tissue calcifications in Raynaud phenomenon possible

39.3 39.4 39.5 39.6

Acral ischemia Common with diabetes mellitus and dialysis patients Pathologic arteriogram

48.1

Spongy transformation of compact bone Brown tumors Primary, secondary, and tertiary forms

31.8 31.9

Soft-tissue shrinkage Contractures with articular malalignment Osteomyelitis as a complication

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55 Acro-osteolyses

Disease Entity

Local Radiographic Signs

Frostbite

U

U U

Electrical injuries

U

U U U U

Mechanical injuries

U

U

Exposure to vinyl chloride Osteoradionecrosis

U U

U U U

Chronic carpal tunnel syndrome Neurogenic: tabes dorsalis syringomyelia diabetes mellitus leprosy Ungual osteomyelitis

U

U U U

U

U U

Osteitis, osteomyelitis

U

Resorption of the unguinal tuberosities and local osteopenia as late complications Ankyloses Premature closure of growth plates possible Resorption of unguinal tuberosities Local osteoporosis Pathologic fractures Contractures Growth disturbance Band-shaped osteolyses on the distal phalanges Often concomitant phalangeal osteoarthritis Resorption of unguinal tuberosity Band-shaped osteolysis Acro-osteolyses Spotty, stringy osteopenia Osteoarthritis and pathologic fractures possible Rarely together with acro-osteolyses Areactive osteolyses on the fingers Later phalangeal penciling Hypertrophic or atrophic Charcot joints Cystic or diffuse destruction of the distal phalanx Soft-tissue swelling Septic arthritis and ankylosis possible Like ungual osteomyelitis

Further Radiographic and Clinical Findings U

U

U U

U

U U

U U U

U

U

U

U U U

U

U

Benign tumors: epidermoid cyst glomus tumor enchondroma bone cyst tuberous sclerosis Malignant tumors: metastases osteosarcoma chondrosarcoma soft-tissue sarcoma

U

U

U

U

Smoothly contoured bone lesions caused by external pressure (”scalloping”) Or idiopathic bone tumor

Geographic or permeating osteodestruction Usually soft-tissue involvement

U U U U

U U

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Figure

Soft-tissue atrophy of the fingertips Occlusion of arteries and veins

Soft-tissue defects from burns Arterial occlusions due to spasms and thrombi

History of an acute or chronic recurring trauma (e.g., guitar player, ball player) Initial Raynaud phenomenon Collagen cutaneous nodules Atrophy and ulcers of the skin Growth retardation in children Malignant transformation possible

35.6

Brachialgia nocturna paraesthetica Phalangeal malalignment due to unstable ligaments and capsules Grotesque osteophytes

35.2

Local inflammatory symptoms Usually a result of injury Predominantly diabetics

41.1

Hematogenous or secondary forms Osteosclerosis during healing

41.2 41.3 41.4

Painful glomus tumor Palpable epidermoid cyst Often spontaneous fractures Epilepsy, adenoma sebaceum, and mental retardation in tuberous sclerosis

44.1 44.2 44.19 44.20 44.21 45.14

Local pain Pain deriving from primary tumor

44.10 44.23

Acro-osteolyses

Disease Entity

Local Radiographic Signs

Sarcoidosis

U U U U U

Multicentric reticulohistiocytosis

U

U

Acro-osteolyses Also acro-osteonecroses Cystic “punched-out” defects Scalloping of compact bone Osteopenia Sharply delineated articular erosions Destruction spreads to the phalangeal shafts

Further Radiographic and Clinical Findings U U U

U

U

U

Epidermolysis bullosa

U

U U U U

Primary biliary liver cirrhosis

U

U U

Pancreatic diseases (inflammatory, posttraumatic, or tumorous)

U

U U

Carcinoid syndrome

U U U

Congenital porphyria

U U U

Pseudoxanthoma elasticum

U U

Pyknodysostosis

U

U

Hajdu–Cheney syndrome

U U U U

Joseph syndrome Shinz syndrome Ehlers-Danlos syndrome

U

U

U

Osteolyses on pointed distal phalanges Inflammatory ankyloses Syndactylies Periostitis Soft-tissue calcifications Erosive arthritis on proximal and distal interphalangeal joints Destructive arthropathy possible Also periarticular calcifications Rarely acro-osteolyses and direct signs of arthritis Local osteopenia Osteoscleroses from bone infarcts Acro-osteolyses Cystic lesions in the phalanges Periarticular osteopenia Resorption of unguinal tuberosities Osteolyses Soft-tissues thinned and calcified Resorption of unguinal tuberosities Calcifications intracutaneous, periarticular, and in vascular walls Unguinal tuberosities hypoplastic or missing Tubular bones of hand short and sclerotic Band-shaped osteolyses Distal phalanges often spared Defects in skin and nails Only becomes manifest in adolescence Acro-osteolyses in the distal phalanges Acro-osteolyses in the distal phalanges Rarely acro-osteolyses

U U

U

U U

U U U

U

U U U

U U

U U U U

U U U U

U U

U U

U U

Acute or chronic arthritis Lungs and visceral organs involved Erythema nodosum

Polyarthritis, rheumatic factor negative Nodules on skin and mucous membranes Xanthelasmas Four clinical forms Synechiae and scarred claw hand Pharyngoesophageal ulcers

Usually affects females Symptoms of liver cirrhosis

Caused by necroses of fatty tissues Arthritic symptoms Subcutaneous nodules Clinical triad: flush, diarrhea, and cardiac symptoms Increased photosensitivity Hemolytic anemia Splenomegaly Degeneration of elastic fibers Autosomal recessive Short extremities Normal trunk length Hypoplastic facial skeleton Autosomal recessive Hypermobile joints Small stature, brushlike hair Susceptibility to fractures Autosomal dominant Recessive inheritance Otherwise healthy Dominant inheritance Cutaneous ulcers Articular malalignment Additional symptoms according to type of syndrome

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Figure 35.1

569

570

55 Acro-osteolyses

Disease Entity Progeria (Hutchinson– Gilford disease)

Local Radiographic Signs U U

U

Osteolyses on distal phalanges Longitudinal calcifications in ligaments and vessels Osteopenia

Further Radiographic and Clinical Findings U U U U U U

Rothmund syndrome

U U U U

Osteolysis carpotarsalis progressive (François)

U

U

Resorption of unguinal tuberosities Osteopenia Soft-tissue calcifications possible Cutaneous and ungual lesions Erosive destruction or even loss of all carpal bones Accelerated skeletal maturity

U U U U

U U

U

Sézary syndrome

U

Acro-osteolyses possible in advanced stages

U

U U

Cleidocranial dysostosis

U U U U

Hypoplastic unguinal tuberosities Short distal phalanges Large metacarpal II Pseudoepiphyses

U U U U

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Figure

Osteolyses in the claviculae Skin as in scleroderma Alopecia Short stature Micrognathia, beak-shaped nose Early death Poikilodermia Cataract Short stature Saddle nose Arthritic symptoms Combined with kidney diseases and hypertension Short stature T-cell non-Hodgkin lymphoma with generalized cutaneous involvement Lymphadenopathy Leukemic blood count Proportional small stature Large head, saddle nose Hypoplastic clavicle Hereditary or sporadic

16.25

571

56

Cystic Bone Inclusions N. Reutter

Disease Entity

Radiographic Signs

Peculiarities, Clinical Symptoms

Figure

Necrotic/Traumatic Posttraumatic hemorrhagic cyst Necrobiotic pseudocyst

U

With a fine osteosclerotic margin Posttraumatic deformity

U

Up to 3 mm in size

U

U U

U U

Avascular osteonecrosis

U U

Cysts next to osteosclerotic areas Later fractures and malalignments

No predisposition Rare on the hand In medullary space No other predisposition Usually lunate and proximal fragment of scaphoid nonunion

20.5 20.7 30.3 30.7 30.18

Limited range of motion Pain

27.8 b 27.12 43.1

Primary asymptomatic scapholunate joint, capitate and ulna head predisposed sites Fibrovascular degeneration of ligamentary attachments Hyaline cartilage intact Secondary synovial lining of cystic walls

43.3 43.5 43.6 44.21

Usually prolonged course Signs of inflammation

43.2

U

U

Distal radius predisposed

U

Enthesopathic Osteoarthritic cyst

U U U

Intraosseous ganglion

U U U U U U U

Cystic form of rheumatoid arthritis

U U U

Subchondral location Osteosclerotic margin Common signs of osteoarthrits Subcortical cyst Communication with joint surface Ligamentary origin Joint space normal No signs of osteoarthritis Sclerotic margin MRI: ligament insertion can show contrast enhancement in florid stage Periarticular cysts Often no osteosclerotic margin Direct signs of arthritis

U U

U

U

U U

U

Infective Brodie abscess Plasma-cell osteomyelitis Skeletal tuberculosis

U U

U

U

Osteosclerotic margin Drainage canal to joint space Punched-out defects without osteosclerotic margin Joint destruction and ankylosis

U U U

Spina ventosa in children Usually post-primary tuberculosis Relatively common

40.4 41.5 41.6

Hyperuricemia Radiographic signs only in chronic disease course Chiragra

34.1 34.2 34.3

Calcium pyrophosphate deposits also in soft tissues

34.4 34.5 34.6

Often associated with dialysis, arthritic complaints Carpal tunnel syndrome

35.3

Systemic Metabolic Gouty arthritis

U

U

U U

Chondrocalcinosis

U

U

Amyloidosis

U

U U

Marginal cysts/erosions (often with trabeculation) Osteosclerotic margin of little density Gouty thorns, gout tophi Osteopenia Subchondral, large ganglion cysts Osteosclerotic margin Cystic intraosseous and subchondral defects in matrix Osteopenia Fine osteosclerotic margin

U U

U

U

U

U

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56 Cystic Bone Inclusions

Disease Entity

Radiographic Signs

Hemochromatosis

U

U U

Xanthomatosis

U U

Subchondral cysts in MP joints II and III Resembles arthrosis deformans Marginal and subchondral sclerosis Cystic lesions Variable in size, location, distribution, configuration, and margins (osteosclerotic vs. permeating)

Peculiarities, Clinical Symptoms U U U

U U

Symptomatic chondrocalcinosis Females predisposed Carpal collapse possible

Figure 34.12

Associated with hyperproteinemia Xanthomas also in cutaneous and subcutaneous locations

Systemic Endocrine Hyperparathyroidism

U

U U U U

Metaphyseal brown tumors in metacarpals and phalanges Usually no osteosclerotic margins Permeating Osteopenia Compact bone tunneled and striated

U U

Hypercalcemia Parathormone elevated

31.8

Hili and lungs usually affected

35.1

Autosomal recessive storage disease

43.7

Hamartous malformation Also after postzygotic gene mutation: McCune–Albright disease 30 % polyostotic

43.8

Usually polyostotic Palpable tumors Skin fibromas

43.9

Systemic Granulomatous Sarcoidosis

U

U

Heart-shaped osteolyses adjacent to osteosclerotic areas Acro-osteolyses

U

Systemic Hereditary Gaucher disease

U U U

Fibrous dysplasia (Jaffé–Lichtenstein disease)

U

Blistery lesions Erlenmeyer-flask-shaped deformity Avascular osteonecroses Mixed lesions with cystic and osteosclerotic areas

U

U U

U

Neurofibromatosis I

U

U

Tuberous sclerosis

U

Oval osteolyses with osteosclerotic margins Periosteal thickening Cystic radiolucencies next to spotty osteoscleroses

U U U

U U U

Lipomembranous osteodysplasia

U

U

Gorlin syndrome Tumors and tumorlike lesions

U

First asymptomatic cystic inclusions in hand skeleton and talus Pathologic fractures in late stage Cysts with osteosclerotic margins in metacarpals and phalanges

U U

U

U U

see Chapter 44

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Adenoma sebaceum Epilepsy Mental retardation Hereditary phacomatosis Brain atrophy due to sclerosing leukencephalopathy Neuropsychiatric symptoms from the age of 30 years Basal-cell nevus syndrome Neurologic deficits

573

57

Polyostotic Bone Lesions H. Rosenthal, R. Schmitt

Disease Entity Enchondromatosis (Ollier disease)

Radiographic Signs U

U

U

Maffucci syndrome

Multiple myeloma (plasmocytoma)

U

U U U

Metastases

U

U

Leukemia

U

U

Melorheostosis

U

U

Osteopoikilosis Hemangioendothelioma/ angiosarcoma Idiopathic carpal osteolysis

U

U U

U

U U

Gorham–Stout osteolysis syndrome (disappearing bone syndrome) Hajdu–Cheney syndrome

U U

Sharply contoured lesions with osteosclerotic margins and calcifications in the cartilaginous matrix Phalanges and metacarpals predisposed Frequent spontaneous fractures Combination of enchondromatosis and soft-tissue hemangiomas Sharply defined osteolyses Solitary or diffuse Spontaneous fracture possible Geographic or permeative osteolyses Usually without any bony reaction Indistinct geographic osteolyses or diffuse permeation Hand skeleton affected only rarely and in advanced stages Drop-shaped osteosclerotic foci like a dripping candle Joints involved Round or oval osteosclerotic foci in medullary space Polyostotic, osteolytic destruction Carpals and metacarpals predominate Carpal bones irregular or even completely destroyed because of erosions Carpal collapse Premature closure of growth plates Extremely rare on the hand Osteolysis can slowly regress

Radiographic and Clinical Peculiarities Unilateral in Ollier disease Extremities short and deformed Malignant transformation possible

16.23

Skeletal deformation Hemangiomas in the skin and internal organs

44.3

Painful bones Anemia, fatigue Proteinuria

44.16

Painful bones Spontaneous fractures Symptoms of the primary tumor dominant

44.23

44.17

U

Anemia, fatigue Fever, lymphadenopathy Gingivitis, hemorrhages Neurologic symptoms

U

Painful limbs

16.26

U

Generally without symptoms

16.27

Rare on the hand Soft-tissue components Pain

44.15

Acute arthritic symptoms Often combined with hypertension and nephropathy

16.25

U U U

U U

U U U

U U U

U U U

U U U

U U

U

U

U U

Band-shaped osteolyses Distal phalanx often spared

U U U U

Neurofibromatosis

U

Oval osteolyses with osteosclerotic margins next to thickened, bulgy soft tissues

Figure

U U U

Posttraumatic or combined with angiomatosis or lymphangiomatosis Painful bones Skin lesions and nail defects Joint hypermobility Short stature, brushlike hair Autosomal dominant Cutaneous neurofibromas, nevi Café-au-lait spots Bone deformities

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43.9

574

57 Polyostotic Bone Lesions

Disease Entity Tuberous sclerosis (Pringle–Bourneville syndrome)

Radiographic Signs U U

Rare in the hand skeleton Cystic osseous inclusions with periosteal thickening

Radiographic and Clinical Peculiarities U U U U

Fibrous dysplasia (Jaffé–Lichtenstein disease)

U

U U

Storage diseases (e.g., Gaucher disease)

U

U U

Sarcoidosis

U

U U U

Histiocytosis X

U

U

U

Deformed bones with cystic and osteosclerotic parts Compact bone thinned Usually one side predominates Irregular, blistery osteolyses in the medullary space Erlenmeyer-flask-shaped deformity Osteonecroses Round or polygonal punched-out defects Beehived bone structure Osteopenia Erosions and soft-tissue swelling possible Hand skeleton rarely involved with punched-out osteolyses Osteosclerotic and periosteal reactions during healing Increased number of growth lines

U U U

U U

U U U

U

U U U

Amyloidosis

U U U

Subchondral cysts and erosions Prominent osteopenia Soft-tissue swelling

U U U U U

Membranous lipodystrophy

U U U

Sickle-cell anemia

U

U

Metastatic necroses of fatty bone marrow (as in pancreatitis)

U

U U

Brown tumors in hyperparathyroidism

U

U

U U

Soft-tissue tumors with bone destruction (as in PVNS and xanthomatosis)

U

U

Accelerated skeletal maturation Overgrowth of tubular bones Lack of subcutaneous fatty tissue and septa Stringy distension of the medullary space Ischemic osteonecroses with areas of increased density and radiolucency Osteoscleroses due to bone infarcts Acro-osteolyses Direct signs of arthritis Smoothly contoured, expanding osteolyses Spongy transformation of the compact bone Osteopenia Soft-tissue calcifications Bone defects with smooth margins and marginal osteosclerosis due to external pressure erosion Local soft-tissue tumor

U U U

U U

U

U U

U U U U

U U U

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Figure

Adenoma sebaceum Epilepsy Mental retardation Angiofibromas Painful bone Bent bones Sometimes spontaneous fractures

43.8

Usually Ashkenazi Jews affected Clinically often first manifest in adulthood

43.7

Hilar lymphadenopathy Arthritic symptoms Erythema nodosum

35.1

Eosinophilic granuloma, Hand–Schüller–Christian and Abt–Letterer–Siwe disease as subgroups Local swelling, pain Hepatosplenomegaly Otitis externa Primary or secondary form Nephrotic syndrome Cardiomyopathy Malabasorption syndrome Carpal tunnel syndrome Lack of fatty tissue Hepatomegaly Hyperlipidemia, diabetes mellitus, hyperpigmentation Hepatosplenomegaly Organ infarcts due to episodes of vascular occlusion Hemolytic anemia Arthritic symptoms Subcutaneous nodules

Bone pain Nephrolithiasis Nephrocalcinosis Ulcers, pancreatitis

31.8

Generally palpable tumors Phalangeal predisposition PVNS mass is hypointense in MRI

44.24

Polyostotic Bone Lesions

Disease Entity Joint diseases (e.g., gouty and neurogenic arthropathy) Osteomyelitis

Radiographic Signs U U U

U

U

U

Marginal erosions Gouty thorns and tophi Hypertrophic Charcot osteoarthritis Corticocancellous bone destruction Sequestrum surrounded by an osteolytic cavity Reactive osteosclerosis and periosteal reaction

Radiographic and Clinical Peculiarities U

U

U U U

Figure

Functional restriction of the joint with or without inflammation Joint malalignment

34.1 34.2 34.3 35.2

Signs of general infection Painful bone Local swelling and hyperthermia

41.2 41.3 41.4

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576

58

Lesions of the Periosteum and Cortical Bone N. Reutter

Distribution

Disease Group or Entity

Radiographic and Clinical Peculiarities

Figure

Widespread Periosteal Hyperostoses Mainly Polyostotic or Oligoostotic

Arterial occlusive disease

U U

Chronic lymphedema

U U

Hemoglobinopathies, childhood leukemia, osteomyelofibrosis/-sclerosis

U U U

U

Hemophilia

U U U

Hypervitaminosis A

U U U

Hypervitaminosis D

U U U

Vitamin C deficiency (scurvy)

U U

Diabetes mellitus

U U U

Thyreohypophyseal acropathy

U

U

Hyperparathyroidism

U

Milk-alkali syndrome

U

U

Prostaglandin-E therapy

U U

Hypertrophic osteoarthropathy

U U U

U

Reactive lamellar periosteal apposition Tubular calcifications of the vessel walls Lamellar, later solid periosteal appositions Usually after breast cancer Periosteal appositions Partially with spiculae Multiple infarcts with diametaphyseal and subchondral thickening Osteopenia

35.4 44.17

Lamellar or radial periosteal reaction Subchondral cysts Pseudotumors, usually on MP joints Ulna predisposed Premature closure of physeal spaces Fibro-ostoses in adults Periosteal ossification Osteopenia Osteosclerotic bands around physes Ossification of subperiosteal hematomas Metaphyseal comminuted zone Generalized hyperostosis Tubular calcification of the vessels Osteopenia EMO syndrome: exophthalmos, myxedema, and hypertrophic osteoarthropathy After therapy for autoimmunologic hyperthyroidism

33.6

Subperiosteal resorption and dissected compact bone resembles periosteal hyperostosis

31.8

Ectopic periosteal calcifications in hypercalcemia Caused by excessive intake of calcium (milk) or antacids Lamellar or solid periosteal formations Partially grotesque after long-term therapy Solid, lamellar or radial periosteal reaction Primary (Touraine–Solente–Golé) Secondary (Pierre–Marie–Bamberger) in pulmonary or intestinal diseases Drumstick fingers, synovitis

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35.5

Lesions of the Periosteum and Cortical Bone

Distribution

Disease Group or Entity

Radiographic and Clinical Peculiarities

Rubella, infectious mononucleosis

U U U

Rheumatoid arthritis (RA), psoriatic arthritis

U

U U

Scleroderma, lupus erythematosus, dermatomyositis/polymyositis, panarteritis nodosa, etc.

Sarcoidosis

U

U

U U U

U U

Chronic intoxication: strontium, phosphorus, fluorine

U U U U

Pachydermohyperostosis

U U

U U U

Melorheostosis

U

Diaphyseal dysplasia (Engelmann–Camurati disease)

U U U

Idiopathic periosteal hyperostosis with hyperphosphatasia

U

U U

Chronic recurrent multifocal osteomyelitis

U U U

Hyperostotic osteopathy

U U U

Paget disease (osteitis deformans)

U U U

Figure

Episodic periosteal reaction Polyarthritis MP and PIP joints predominantly affected Periarticular and diaphyseal periosteal hyperostoses Typical pattern of distribution Direct signs of arthritis

28.4 36.2 36.3 36.4 36.5 37.2 37.3 37.4 37.5

Lamellar or irregular periosteal hyperostoses Diaphyseal next to soft-tissue reactions

39.1 39.2 39.3 39.4 39.6 39.7

Periosteal ossification Scalloping of compact bone Round or heart-shaped, punched-out lesions Osteopenia and osteosclerosis Rarely acro-osteolyses

35.1

Lamellar or solid periosteal reaction Osteosclerosis of cancellous bone Metaphyseal lines of increased density Fibro-ostoses Solid periosteal apposition possible Generalized bone thickening with hyperostoses Acro-osteolyses Dominant inheritance Drumstick fingers Wavy formations on the outer side of the compact bone (dripping candle)

16.27

Excessive periosteal sclerosis Thickening of diaphyseal compact bone Autosomal dominant inheritance Solid, generalized broadening of compact bone Very rare Familial occurrence Fine periosteal reaction Children and adolescents Usually no evidence of pathogen

41.8

Adults Alkaline phosphatase elevated Often after febrile infection Thickened compact bone Increase in bone volume Rare on the hand

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44.22

577

578

58 Lesions of the Periosteum and Cortical Bone

Distribution

Disease Group or Entity

Radiographic and Clinical Peculiarities

Pustulous arthro-osteitis (SAPHO syndrome)

U U U

Caffey syndrome

U

U

Battered-child syndrome

U

U U

Mainly Mono-ostotic

Mechanical, thermal, electrical traumas

U

U U U U

Exogenous spreading osteomyelitis

U U U U

Florid reactive periostitis (synonyms: parosseal fasciitis, myositis ossificans circumscripta) Arteriovenous malformation, Klippel–Trénaunay syndrome

U U U

U

U

Cortical osteoid osteoma

U U

Radiation osteopathy

U U U U U

Figure

Pustulous palmar and plantar lesions Arthritic symptoms Chronic recurrent Infantile cortical hyperostosis of the metacarpal bones Obliteration of medullary space Periosteal hyperostoses (callus) of the diaphyses Irregularly distributed fractures Subperiosteal new bone formation on metaphyses Lamellar or solid fracture callus or old periosteal hematoma Soft- tissue shrinkage Contractures Osteopenia Growth disturbance Strong periosteal reaction Permeating osteolysis Soft-tissue swelling Osteosclerosis when chronic

41.1 41.2 41.3 41.4

Solitary periosteal calcification Soft-tissue swelling Traumatic or idiopathic Periosteal hypertrophy and exostoses caused by pressure Isolated macrodactyly

48.17

Eccentric, very dense hyperostosis Central radiolucency of nidus possible

44.11 44.12

Diffuse hyperostoses Diffuse decalcification Pathologic fractures Osteonecroses Malignant transformation possible

35.6

Comblike tenoperiostoses that increase with age Cone-shaped epiphyses Spade-shaped distal phalanx Paw hand

28.2

Usually on distal part of radius During growth

44.6

Periosteal Hyperostoses Resembling Exostoses Mainly Polyostotic

DISH syndrome, acromegaly

U

U U U

Mainly Mono-ostotic or Oligo-ostotic

Cartilaginous exostosis

U U

33.1

44.7 44.8

Tuberous sclerosis

U

U U U

Bony formations on the outside of the compact bone Rarely osteomas Cystoid lesions Epilepsy, mental retardation

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Lesions of the Periosteum and Cortical Bone

Distribution

Disease Group or Entity

Radiographic and Clinical Peculiarities

Gardner syndrome

U

U U

Figure

Bone formations on the lateral aspect of compact bone Sometimes as osteoma Intestinal polyposis

Intermittent and Complex Periosteal Reactions Mainly Polyostotic

Leprosy

U U

Frambesia (yaws)

U U

Congenital syphilis and stages II and III of syphilis Tuberculous osteomyelitis

U U

U

U

Hemophilic arthropathy, leukemic bone infiltrations

U U

U

Neurofibromatosis I

U U U

Rickets, hyperparathyroidism, renal osteopathy

U U U U U

Mainly Mono-ostotic

Periosteal lipoma

U U U

Periosteal amyloid tumor

U U U

Subperiosteal osteoid osteoma

U

U

Osteoblastoma

U U

Osteoblastic osteosarcoma

U

U

Ewing sarcoma

U U U

Bone metastases

U U U

Periosteal and acral lytic defects Erosive joint destruction Lamellar, irregular periosteal appositions With hypertrophic osteitis or periostitis Lamellar periosteal reaction Otherwise like tuberculosis Lamellar periosteal reaction, honeycombed and motheaten osteolyses Spina ventosa in childhood

41.5

Lamellar or arched periosteal reaction Subperiosteal osteoscleroses and pseudotumors Osteolyses

44.17

Solid periosteal thickening Oval osteloyses with osteosclerotic margin Soft-tissue tumors

43.9

Lamellar periosteal reaction Generalized osteopenia Blurred cancellous bone Tunneled and striated compact bone Soft-tissue calcifications

31.6

41.6

31.8 31.9 33.7

Periosteal lamellae Flat erosions in compact bone Honeycombed hyperostosis Superficial bone erosions Cystoid punched-out defects Osteopenia

35.3

Periosteal reaction with hourglass-shaped shell Calcified nidus

44.11 44.12

Lamellar periosteal thickening Larger than an osteoid osteoma Raised periosteum with Codman’s triangle and spiculae Amorphous calcifications Lamellar periosteal reaction with spiculae Permeating osteolysis Diaphyseal region Lamellar periosteal reaction Geographic osteolysis Rare

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44.23

579

580

59

Hyperostoses N. Reutter

Disease Entity

Radiographic Signs

Clinical Peculiarities

Figure

Congenital Hyperostoses Osteopetrosis

U

U U

Endosteal cortical hyperostosis

U

U

Progressive diaphyseal dysplasia (Engelmann–Camurati) Osteopoikilosis

U U

U U

Generalized increase in bone density “Bone in bone” Fractures Thickened compact layer in tubular bones Narrowed medullary space On long tubular bones Increased volume of diaphyses due to new periosteal and endosteal bone formation Round densities in cancellous bone Usually periarticular

U U

U

U

U U

U U U

Osteopathia striata

U U

Melorheostosis

U

U

Mixed sclerosing bone dysplasia

Pyknodysostosis

U

U U U

U

Sclero-osteosis

U U U

Metaphyseal dysplasia (Pyle disease) Fibrogenesis imperfecta ossium

U U

U U

Striped densities in the epiphyses Spotty in the carpal bones Thickened cancellous bone resembles dripping wax Segmental distribution Combination of melorheostosis, osteopoikilosis, and osteopathia striata Generalized osteosclerosis Malunion of fractures Dysplastic fingers with lateral angulation Acro-osteolysis Cortical hyperostosis Syndactyly of fingers II and III Radial clinodactylies Metaphyses widened Especially in distal forearm Patchy increase in bone density Deformities

U U

U

U

Gardner syndrome

U U

Patchy increase in bone density (rarely as osteomas) Cystic radiolucencies Juxtacortical osteoma Osteoplastic new bone formation

Autosomal recessive (van Buchem) Autosomal dominant (Worth)

Asymptomatic Predominantly males Dominant inheritance

U

See Chapter 16

U U

U

U U U

U U

U U

U U U

U U

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16.26

Asymptomatic Congenital

U

U

16.24

Autosomal dominant Concomitant muscle dystrophy

Soft-tissue swelling Chronic pain Decreased range of motion

U

U

Tuberous sclerosis

Cranial-nerve deficits Excessive new bone formation exceeds bone destruction

Nanosomia Hypoplasia of nails and facial skeleton Autosomal recessive Very tall Africans Hypoplastic middle part of face Cranial-nerve deficits Genu valgum Autosomal recessive Spontaneous fractures Deformities Congenital Epilepsy Adenoma sebaceum Mental retardation Intestinal polyposis Hereditary

16.27

Hyperostoses

Disease Entity

Radiographic Signs

Clinical Peculiarities

Figure

Acquired Hyperostoses DISH syndrome

U U U

Osteomyelofibrosis Lipoatrophic diabetes mellitus Hypertrophic osteoarthropathy Bone marrow infarction, osteonecrosis

U

U U

U

U U

Chronic osteomyelitis

U

Sarcoidosis

U U U U

Paget disease

U

U

Atypical form of hyperparathyroidism Pustulous acro-osteitis (SAPHO syndrome)

U

U

Fibro-ostotic formations Marginal osteosclerosis Subchondral osteoscleroses Bone structure resembles frostedglass Thickening of compact bone Metaphyseal osteosclerosis Periosteal ossifications on the diaphyses of the hand Patchy, indistinct osteoscleroses Adjacent osteolyses possible Patchy, indistinct osteoscleroses adjacent osteolyses Periosteal ossifications Scalloping of compact bone Heart-shaped osteolyses Osteopenia and osteoscleroses Increase in size and density of bones Patchy osteosclerosis and osteolyses Patchy or homogeneous osteosclerosis Sclerotic periosteal formations

U U

U

Extramedullary hematopoesis Splenomegaly

U

Unknown etiology

U

U

Homogeneous osteosclerosis and thickening of trabeculae, cysts possible

28.2

U

Idiopathic In pulmonary or intestinal diseases Drumstick fingers

U

Asymptomatic or local pain

U

Relatively few symptoms

41.7 41.8

Hilar lymph nodes and lungs involved

35.1

Usually affects skeleton of trunk and skull

44.22

U U

U

U

U U

U

U

Mastocytosis

Idiopathic Often in diabetes mellitus, spondylitis ankylosans, or fluorosis

U

35.5

Hypercalcemia Parathyroid hormone elevated Pustulous lesions palmar and plantar Arthritic symptoms Skeleton of the trunk primarily affected

Intoxication/Poisoning Fluorosis

U U

Lead poisoning Strontium poisoning

U

U

U

Retinoid/vitamin A poisoning Bone tumors

Diffuse osteosclerosis Ossification of periosteum and ligaments Osteosclerotic epiphyseal and metaphyseal “lead bands” Osteosclerosis of compact and cancellous bone Malignant transformation possible

U

Enthesopathy Hyperostoses even in childhood

U

Refer to Chapter 44

U

U U

U U

Pain in bones and muscles Pathologic fractures Anemia Neurologic symptoms

U

Stimulation of osteoblasts Inhibition of osteoclasts

U

Growth disturbance

U

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33.9

581

582

60

Osteopenia N. Reutter

Disease Entity

Radiographic Signs

Osteoporosis

U U U

Increased radiolucency Stringy cancellous bone Accentuated compact bone

Occurrence

Figure

Generalized: Idiopathic U Postmenopausal U Senile U Endocrine: – Lack of sexual hormones – Hypercortisolism – Hyperthyroidism U Intestinal: – Malabsorption – Maldigestion U Neoplastic: – Multiple myeloma – Mastocytosis – Leukemia U Hereditary: – Hemoglobinopathies – Storage diseases – Connective-tissue diseases

31.1 31.2

U

Localized: Inactivity U Algodystrophy U Rheumatoid arthritis U Osteomyelitis U Regional disturbance of circulation U

Osteomalacia

U

U U

Structure of cancellous bone blurred Tunneling in compact bone Looser remodeling zones

U

U

U U U U

U

Vitamin D deficiency – Alimentary – Malabsorption – Lack of UV light – Metabolic : disturbed renal/ hepatic synthesis Calcium deficiency: – Alimentary – Enteral loss – Tubular nephropathies Phosphate deficiency Aluminum poisoning Oxalosis Medication: – Antiepileptics (phenytoin) – Magnesium sulfate, laxatives – Cholestyramine, rifampicin – Diphosphonate Associated with: – Neurofibromatosis – Fibrous dysplasia – Lupus erythematosus

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31.7

Osteopenia

Disease Entity

Radiographic Signs

Rickets

U U U U

U

Hyperparathyroidism

U

U U U U

Renal osteopathy

Growth retardation Widened growth plate Cup-shaped metaphyses Comminuted zone in the metaphyseal end plate Curved tubular bones Tunneling and trabeculation of compact bone Rarefied cancellous bone Acro-osteolyses Brown tumors Soft-tissue calcifications

U

Combined symptoms of osteomalacia and hyperparathyroidism Also caused by aluminum and amyloid deposits Osteoporosis Osteonecroses Pseudocysts

U

Reduced bone mass

U

U

U U

Hypoparathyroidism

Occurrence U

U

U

U

U

U

U

U

Figure

Occurs on the growing skeleton because of lack of UV light (insufficient synthesis of 1,25-dihydroxycholecalciferol) Lack of sufficient vitamin D intake (very rare)

31.6

Primary form: adenoma of the parathyroid gland Secondary form: usually renal etiology, disturbed calcium homeostasis Tertiary form: autonomy after preexisting secondary hyperparathyroidism

31.8

Renal failure of different etiologies

31.9

Inherited: – Isolated – Associated with other endocrinopathies Acquired: – Parathyroidectomy

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31.7

583

584

61

Soft-tissue Calcifications R. Schmitt, G. Christopoulos

Disease Entity

Radiographic Signs in the Hand

Chondrodysplasia punctata

U U

Puntate amorphous calcifications In the carpus

Other Radiographic and Clinical Signs U U U U

Dysplasia epiphysealis hemimelica (Trevor disease) Myositis ossificans progressive

U

U

U U

Osteochondroma-like exostoses in the carpus Local increase in growth Calcifications along the tendons Rare

U

U

U U

Progeria (Hutchinson– Gilford syndrome)

U

U U

Arteriosclerosis Diabetes mellitus

U

Longitudinal calcifications on ligaments and vessels Osteolyses on the distal phalanges Osteopenia Tubular calcification of vascular walls

U U U U

U

U

Raynaud phenomenon (secondary)

Hemangioma

U

Acral and peritendinous calcifications (calcinosis circumscripta) Subcutaneous

U

Phleboliths in soft-tissues

U

U U

U

U

Hyperparathyroidism

U

Calcifications in soft-tissues, cartilage, and vessel walls possible

U

U U

Milk-alkali syndrome (Burnett syndrome) Renal osteopathy

U

U

U

Hypoparathyroidism

U U

Hypervitaminosis D

U U

Diffuse “tumorous calcinosis” in inflamed soft-tissues Amorphous periarticular softtissue calcifications In secondary or tertiary hyperparathyroidism Soft-tissue calcifications possible Acro-osteoscleroses Diffuse calcifications Periarticular and in vessel walls

U U

U U U

U U

U

U U

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Figure

On short tubular bones Scoliosis, skin lesions Flat face Type I (Conradi–Hünermann) or II (rhizomelia) Mostly in the lower extremity (knee and ankle) Hypoplasia of the thumb and little finger Painful soft-tissue swelling Congenital connective-tissue disease Skin lesions as in scleroderma Alopecia Microsomia, micrognathia Early death Soft-tissue defects and osteomyelitis in stage IV Osteopenia

48.1

Occlusion of digital arteries In scleroderma, less often in poly-/dermatomyositis

39.3 39.4 39.5 39.6

Maffucci syndrome = concomitant enchondromatosis Klippel–Trénaunay syndrome = concomitant macrodactyly

44.3 45.12 48.17

Compact bone tunnelled and striated Acro-osteolyses Brown tumors

31.8 31.9

With excessive milk intake Hyperphosphatemia Osteomalacia Hyperparathyroidism Amyloid osteopathy Reduced bone mass Hereditary or after parathyroidectomy Osteoscleroses adjacent to the growth plates Osteopenia Periosteal bone apposition

31.9

Soft-tissue Calcifications

Disease Entity CPPD deposition disease (pseudogout)

Radiographic Signs in the Hand U U U

Indistinct, spotty calcifications In TFCC and carpal ligaments Carpal instability

Other Radiographic and Clinical Signs U

Subsequent osteoarthritis

Figure 34.4 34.5 34.6

Tumorous calcinosis (Teutschländer syndrome)

U

U U

Acute hydroxyapatite calcium deposition

U

U

Gout osteoarthropathy

U U

Distinct calcium deposits in soft tissues Ring-shaped or amorphous Periarticular on distal interphalangeal joints and on fingertips Sharp-edged or cloudy, amorphous calcifications Predominantly near pisiform, in carpal tunnel, and on palmar side of proximal interphalangeal joints Streaky, faint calcifications In urate tophi of soft tissues

U U U

U

U

U

U U

Ochronosis (alcaptonuria) Oxalosis

U

U U

U U

Fluorosis

U U

Intraarticular and periarticular calcifications Periarticular calcifications Rarely on the hand Diffuse calcifications In soft tissues, articular cartilage, and vessel walls Phalangeal periostitis Later soft-tissue calcifications

U U

U

U U

U

U

Myositis ossificans

U U U

Osteoligamentary avulsion injury Chronic repeated injuries of the fingertips Neurogenic arthropathy (Charcot joint) Osteoarthritis, osteochondromatosis

U U

U

U U

U

U

Rheumatoid arthritis (RA)

U U

Posttraumatic calcifications Zonal formation: Central soft-tissue density, fine peripheral ossifications Small ossifications Posttraumatic sequel Fine calcification next to tuberosities Intra-articular loose bodies Mostly calcified Calcifications of intra-articular cartilaginous fragments Round, stratified form Very rarely granular calcifications In pannus

34.7

Acute inflammation with softtissue infiltrations Regression with immobilization

34.9

34.8

34.10 34.11

U

Hemochromatosis

Special form of CPPD Males and blacks predominate Also toes, hips, elbows, and thoracic wall affected

U

U

U

U U

U

U U

Marginal erosions, gouty thorns in long-standing disease Destruction of bones Osteopenia Thumbs predominately affected

34.1

Osteoarthritis of MP joints II and III Later also of carpal bones

34.12

34.2 34.3

Destructive arthropathy as in rheumatoid arthritis Signs of rickets in children Signs of renal osteopathy in adults

34.13

Spotty osteoscleroses of cancellous bone Fibro-ostoses Calcifications at a distance from adjacent bones

Corresponding defect on adjacent bone

21.1

Damage to collagen fibers in the distal phalangeal tuberosity Carpal and digital instabilities Grotesque osteophytes

35.2

Often deforming osteoarthritis of the carpus or SLAC wrist

35.8

Collateral signs of arthritis Direct signs of arthritis

36.2 36.3 36.4 36.5

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586

61 Soft-tissue Calcifications

Disease Entity

Radiographic Signs in the Hand

Psoriatic arthropathy

U

Subungual calcifications or irregular fibro-osteitis

Other Radiographic and Clinical Signs DIP prevalence Erosions and even “pencil-in-cup” form Osteopenia Psoriatic dactylitis

37.2 37.3 37.4 37.5

Cystic inclusions in cancellous bone Acro-osteolyses

35.1

In various collagenoses Scleroderma predominates

39.3

Areactive acro-osteolyses Sclerodactyly Destructive polyarthritis in 25 % of cases

39.3

Severe articular malalignment without joint destruction Osteonecroses

39.1

Rarely osteopenia and erosions in joints Internal organs affected

39.6

Polyarthritis without joint destruction Periosteal lesions in diaphyses Microaneurysms

39.7

U

Direct signs of arthritis Periarticular osteopenia Cystic carpal tuberculosis

40.2 40.3 40.4

U

Extremely rare in the hand

U U

U U

Skeletal sarcoidosis

U U

Periarticular calcifications Resulting from hypercalcemia

U

U

Localized interstitial calcinosis

U

U

Scleroderma

U U

Lupus erythematosus

U

Calcium deposits in subcutaneous tissue necroses Fingertips, finger pulps, and bony prominences Spotty calcifications Subcutaneous acral and periarticular (calcinosis circumscripta) Calcified capsules in finger joints (peritendinitis calcarea)

U U

U U U

U

U

Dermato-/polymyositis

U U

Panarteriitis nodosa

U

Plaquelike calcifications Subcutaneous and striped in fasciae and muscles (calcinosis circumscripta) Periarticular calcifications possible

U

U

U

U U

Bacterial or tuberculous arthritis Cysticercosis, echinococcosis, trichinosis, bilharziosis, loa loa, etc. Xanthoma

U

U U

U U

Pseudoxanthoma elasticum

U

Rarely intraarticular/periarticular calcification of abscesses or sequestra Round or U-shaped calcifications Located in the longitudinal axis of the hand muscles In the soft tissues of the fingers Delineated, low-density calcifications Intracutaneous calcifications around joints and in vessel walls

U U

U U U

U U U

Fibroma

U

Faint or plaquelike calcifications

U

Lipoma

U

Calcifications in tumor

U

Periosteal chondroma

U

Neurinoma, neurofibroma

U

U

“Popcorn” or flame-shaped calcification of the cartilaginous tumor matrix Inhomogeneous, round or ringshaped calcifications within tumor Rare

Figure

U

U

U

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39.4

39.4

39.2

Often symmetrical Osseous pressure erosions possible Special form of PVNS Resorption of ungual tuberosity Degeneration of elastic fibers Autosomal recessive Osseous pressure erosions possible

45.6

CT attenuation approx. −100 HU

45.5

Especially metacarpals and phalanges affected Very rare

44.4

Osseous pressure erosions in neurofibromatosis

45.17

44.5

Soft-tissue Calcifications

Disease Entity Soft-tissue sarcomas (liposarcoma fibrosarcoma synovial sarcoma)

Radiographic Signs in the Hand U

U

U

Paraosseous osteosarcoma

U

Iatrogenic calcifications

U

Idiopathic soft-tissue calcifications

Spotty or linear calcifications of tumor matrix

Other Radiographic and Clinical Signs

U U

“Popcorn” or smudgy calcifications Calcifications in joints or vessel walls Subcutaneous calcifications Can drain on pressure

Noncalcified tumorous soft tissues predominate Rarely erosion or scalloping of the adjacent bones

U

Very rare on the hand

U

Usually after steroid injections

U

Probably originate after spontaneous fat necroses

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Figure 45.10 45.11

587

588

62

Secondary Raynaud Phenomena H. Rosenthal

Disease Category

Disease Entity

Arterial occlusions

U U U

Collagenoses

U U U U U U U U U

Neurologic diseases

U U U U U U U U U

Shoulder-girdle syndromes

U U U U

Spinal diseases

Obliterating atherosclerosis Endarteritis obliterans Embolism

48.1 48.3 48.4 48.6

Progressive scleroderma CREST syndrome, Sharp syndrome Disseminated lupus erythematosus Wegener granulomatosis Dermatomyositis Panarteritis nodosa Rheumatoid arthritis (RA) Dupuytren contracture Eosinophilic fasciitis

39.7 48.8

Multiple sclerosis Neuritis Poliomyelitis Syringomyelia Spinal tumors Cerebral endarteritis Apoplectic insult Causalgia Carpal tunnel syndrome Scalenus-anterior syndrome Cervical rib Costoclavicular syndrome Hyperabduction syndrome

U

Scoliosis Spondylosis/spondylarthrosis of cervical spine Rheumatoid spondylitis

Hepatic diseases

U

Liver cirrhosis

Venous occlusions

U

Thrombosis of axillary veins

Arteriovenous shunts

U

U U

U

Dysplasia of arterial vessels Arteriovenous malformations Cimino–Brescia shunt

Uremia

U

Hemodialysis

Pulmonary diseases

U

Primary pulmonary hypertension

Cardiovascular diseases

U

Hypotension

Hematogenous diseases

U

U

U U U U

Figure

Cold-agglutinin syndrome Cryoglobulinemia Polycytemia Paraproteinemia Multiple myeloma (plasmacytoma)

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48.2

48.17 48.18 48.19 48.20

Secondary Raynaud Phenomena

Disease Category

Disease Entity

Endocrinological diseases

U U U

Poisoning

U U U U

Medicinal adverse effects

U U U

Injuries

Disturbances in lymphatic drainage Bacterial infections

Norepinephrine, beta-blockers, clonidine Hormonal contraceptives Bleomycin, vinblastine

U

Carcinomas

U

Thesaurismoses (storage diseases)

Polyvinyl chloride Arsenic, lead Ergotamine, serotonin Cyanide, poisonous mushrooms, olefin

U

U

Paraneoplastic syndromes

Hypoparathyroidism Hypothyroidism Pheochromocytoma

Localized injuries and operations Occupational vibration traumas Occupational localized thermal influences Radiation

U

U

Angiokeratoma corporis diffusum (Fabry disease)

U

“Yellow nail” syndrome

U

Entamoeba histolytica

U

Figure

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48.9 48.10 48.11 48.12 48.13 48.15

589

590

Index

Index Page numbers in italics refer to pages with illustrations.

A Abbaszadegan’s method 190 abductor digiti minimi, accessory 156 abductor pollicis brevis, MRI 91 abductor pollicis longus, intersection syndrome of extensor pollicis brevis and 336 abductor pollicis longus tendon MRI 91 variants 155 abscess Brodie 464, 482, 571 palmar deep space 471, 472 accessory carpal bones/ossicles 153–154 carpometacarpal dislocations/fracturedislocations vs 296 achondroplasia congenita 556 acoustic energy and depth of penetration 55 acoustic impedance 54 acquisition of images CT, parameters 65–66 digital subtraction angiography 41 acrocephalodactyly 552 type I 166, 552 types II–V 166, 552 acromegaly 327, 331, 384, 578 diagnostic imaging 327, 394 pathoanatomy and clinical symptoms 384 therapeutic options 391 acro-osteolyses 567–570 acropathy, thyreohypophyseal 557, 576 acrosyndactyly 165, 173 adductor pollicis, MRI 91, 93 adrenogenital syndrome 385–386 agammaglobulinemia 440, 563 age, skeletal, determination 146, 147–148 Ahlbäch’s method 220 Aitken’s classification of metaphyseal and epiphyseal fractures 188, 310 Albers–Schönberg disease (osteopetrosis) 559, 580 alcaptonuria (alkaptonuria; ochronosis) 331, 401, 565, 585 algodystrophy (complex regional pain syndrome type I) 377–382 diagnostic criteria 377 diagnostic imaging 379–380 differential diagnosis 381 pathoanatomy and clinical symptoms 377–379 skeletal scintigraphy 51 therapeutic options 382 alkaptonuria (alcaptonuria; ochronosis) 331, 401, 565, 585 allergic reactions to angiographic contrast agents 41 aluminium osteopathy 390, 391 American Rheumatism Association criteria for rheumatoid arthritis 419 amino acid and protein metabolism, disorders 177, 561

amputations congenital 160, 173 traumatic, surgery 142 amyloidosis (and associated osteoarthropathy) 482, 565, 571, 574 dialysis-associated 408, 498 focal/nodular (amyloid tumor), periosteal 579 anatomic variants 36–40 arthrography (wrist) 25–26 skeleton 151–154 soft tissues 155 muscle see muscle anatomical snuff box, MRI 91 aneurysmal bone cyst 497 see also false aneurysm angiography (predominantly arteriography) 36–44 bone tumors 487, 544 hemangioma 494 diagnostic use 40–44 digital subtraction see digital subtraction angiography soft-tissue tumors 503, 544 hemangioma 513 specific differential applications 43–44 vascular disorders 536 arteriovenous malformations 545, 546 congenital malformations 544 endangitis obliterans 538–539 panarteritis nodosa 449, 540 peripheral embolism 537 peripheral vascular disorders 536 rare diseases 541 Raynaud disease 540 scleroderma 540 systemic lupus erythematosus 540 thenar/hypothenar-hammer syndrome 542 traumatic lesions 541, 542, 543–544 tumors see subheadings above angiosarcoma bone 494, 573 soft-tissue 515 angles carpal 125–126 in instability 272 radius 123 ankylosing spondylitis (Marie–Strümpell disease; Bechterew syndrome) 332, 433, 563 differential diagnosis 438, 563 HLA and 432 pathoanatomy and clinical symptoms 438 radiography 438 reactive arthritis and 437 Reiter’s syndrome and 436 therapeutic options 438

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antibiotics acute bacterial arthritis 454 tuberculous arthritis 455 antibody-deficiency syndromes (agamma/ hypogammaglobulinemia) 440, 563 anular pulley injuries 342–343 AO/ASIF, distal radius fracture classification 183, 188 Apert–Crouzon syndrome 552 Apert syndrome 166, 552 aphalangia 160 aplasia, thumb 171 arcuate (triquetrocapitoscaphoid) ligament anatomy 102 MRI 111 artefacts (artifacts), CT 65 arteries access for arteriography 40 anatomy and variants 36–40 occlusive disease 576, 584, 589 see also arteriosclerosis radiation damage 543 ultrasound, normal findings 58 arteriography see angiography arteriosclerosis and atherosclerosis 536, 567, 584 see also arteries, occlusive disease arteriovenous malformations 494, 545–546, 578 arteriovenous shunts, Raynaud phenomena 588 arteritis, giant-cell 541 arthritis 562–566 bacterial see bacterial arthritis cystic lesions 479–481, 498 degenerative see osteoarthritis Dihlman’s direct signs (radiography) 432 enteropathic 432, 439–440, 561 foreign-body 413–414 gouty see gout infectious/septic see infectious arthritis Jaccoud’s 442, 443 MRI see magnetic resonance imaging polyarticular see polyarthritis psoriatic see psoriasis reactive see reactive arthritis rheumatoid see rheumatoid arthritis in sarcoidosis 404 scintigraphy see scintigraphy seronegative 332 tuberculous 454–455, 563, 579, 587 arthrodermatitis, lipoid (multicentric reticulohistiocytosis) 410, 565, 569 arthrodesis distal radius fracture malunion 195 osteoarthritis 327 phalangeal joints 140 wrist/carpus 140 wrist/carpus, partial 133–134 in scaphoid non-union 241–242 arthrography 23–29

Index

anatomical considerations 23 carpal instability 272–273 lunotriquetral dissociation 283 scapholunate dissociation 278–279 carpal ligaments 112 CT see computed tomography arthrography indications and assessment 28–29 infectious arthritis 452 large joint spaces 24–26 MR see magnetic resonance arthrography multicompartment 24–25, 27, 28 small joint spaces 27 triangular fibrocartilage complex 26, 121, 207–212 ulnar styloid bursitis 348 arthrogryposis (multiplex congenita) 164, 552 arthro-ophthalmopathy 556 arthro-osteitis, pustular (SAPHO syndrome) 440, 577, 581 arthropathies combined osteopathies and see osteoarthropathies crystal-induced see crystal-induced arthropathies enteropathic 432, 439–440, 563 arthroplasty (joint replacement/prosthesis) finger joints metacarpophalangeal joint 138 proximal interphalangeal joint 138, 140 resection, trapeziometacarpal joint 138 arthroscopic surgery (therapeutic arthroscopy) indications 34 triangular fibrocartilage complex lesions 34, 207 arthroscopy (diagnostic/in general) 30–35, 215 access 31 carpal instability 273 carpal ligaments 99, 112 contraindications and complications 34 distal radius fracture 194 associated distal radioulnar joint injury 198 malunion 196 equipment 30–31 indications 33 lunotriquetral dissociation 284 normal findings 32–33 triangular fibrocartilage complex 33, 121, 207 articular cartilage “double-line” sign see “double-line” sign MRI 89 in osteoarthritis abnormalities in etiology 316 damage 316 increased pressure on normal cartilage in etiology 316 ultrasound 58 articular malalignment/malfunction of carpus 130–131 artifacts, CT 65 ascorbic acid (vitamin C) deficiency 389, 574 ASPED syndrome 159 asphyxiating thoracic dysplasia 557

Association for the Study of Internal Fixation (AO ASIF), distal radius fracture classification 183, 188 atherosclerosis and arteriosclerosis 536, 567, 584 atrophy soft-tissue, in scleroderma 447 terminal, in algodystrophy 379 autoimmune thyroiditis 440, 563 avascular osteonecrosis 571 carpus 479 scaphoid (fracture) 218, 230, 264, 479 avulsion fractures/injuries 585 fingers 305, 308–310, 312 ligaments 362 distal radius 183 lunate 249 trapezium 255 triangular fibrocartilage complex 197 triquetrum 104, 246 axes of movement, carpal 127 axial carpal instability 270, 271 axial dislocation/fracture dislocation of carpus 260, 267 axial malrotation of radius 192, 194 axial multiplanar reconstruction images 67

B B-mode ultrasonography 55 pulsed Doppler combined with 56 bacterial arthritis 332, 587 acute 452, 453, 454, 564 Barnet–Nordin metacarpal index 367 Barton’s fracture 182, 183 reversed 182, 183 battered-child syndrome 578 Bayley–Pinneau method of height prediction 150 Bechterew syndrome see ankylosing spondylitis Behçet disease 432, 440, 563 bending fractures of distal radius metaphysis 183 Bennett’s fracture 299–300 bidirectional defects in wrist 25 bilharziosis arthropathy 456 biliary liver cirrhosis, primary 439, 569 bipartite scaphoid 153, 240 bites osteomyelitis 464 vascular injury 544 bladder exposure, skeletal scintigraphy 47 bleeder’s joints (hemophilic osteoarthropathy) 407, 565, 579 blood vessels contrast radiography see angiography tumors derived from 513–515 ultrasound, normal findings 58 see also entries under vascularBoeck disease see sarcoidosis bone anatomy 366 bruises (traumatic) 261, 362 cortical lesions 576–579 density measurement (osteodensitometry) 367–371 in algodystrophy 379 in osteoporosis 367–371 fractures see fractures metabolism 366

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polyostotic lesions 573–575, 576–578, 578, 579 resorption see resorption scintigraphy see scintigraphy tumors see tumors ultrasound, normal findings 58 variant anatomy 151–154 see also osseous structure; osseous structures; skeleton and specific bones bone cysts/cystic lesions 478–485, 568, 571–573 aneurysmal 497 arthritic 479–481, 498 classification 478 differential diagnosis 485 no pathological relevance 478–479 pathogenesis and clinical symptoms 478 scaphoid 240, 481 solitary 498 therapeutic options 485 bone island (enostoma) 497 scaphoid 240 bone marrow bone tumors derived from 496 hyperplasia in hemoglobinopathies 409 infarction 571 inflammatory disease/infection see osteomyelitis metastatic necroses of 574 MRI 89 lunate osteonecrosis 358, 359 rheumatoid arthritis 425 bone tumors 486–501, 579 cystic 478, 485 diagnostic imaging 487 angiography see angiography CT see computed tomography MRI see magnetic resonance imaging scintigraphy see scintigraphy incidence of various types 486 malignant see malignant tumors pathoanatomy and clinical symptoms 486 secondary see metastases therapeutic options 500 borreliosis (Lyme disease), arthritis 458 Bouchard’s nodules 318 Bower’s procedure of ulnar head 134, 140 brachial artery puncture for needle angiography 40 brachybasophalangia 171 brachydactyly 171–172 brachymesophalangeal triphalangy type 169 brachymesophalangia 172 brachymetacarpia 171, 174 brachytelephalangia 172, 174 breast feeding (lactation), skeletal scintigraphy contraindications 47 Brewerton projection 10 Bridgeman’s projection 6, 7, 220 Brodie abscess 464, 482, 571 “brown tumors” (osteitis fibrosa cystica) 373, 483, 499, 574 bubbles as ultrasonographic contrast agents 56 Buerger disease 538–539 Burnett (milk-alkali) syndrome 576, 584 burns 567 bursitis, ulnar recess 347–348

591

592

Index

C Caffey disease 364, 578 calcifications, soft-tissue 502, 584–587 in carpal tunnel syndrome 526 iatrogenic and idiopathic 587 in scleroderma 447, 586 calcinosis localized interstitial 586 tumorous 397, 585 calcitonin 366 calcium deposits in crystal arthropathies 331 calcium hydroxyapatite see hydroxyapatite crystals calcium pyrophosphate see chondrocalcinosis carpal tunnel syndrome and 526, 527 homogentisic acid (=alcaptonuria/ ochronosis) 331, 401, 565, 585 calcium metabolism, disorders 177, 561 callus distractions 141 formation 48 camera, high-frequency 20 camptodactyly 162–163 cancer see malignant tumors capitate fracture 251–252 child 257 hamate fusion with 151 longitudinal axis determination 125 osteonecrosis of head of 363 see also scaphoid-capitate fracture syndrome capitohamate ligament, anatomy 100 capitolunate instability 288 Caplan syndrome 420, 562 carbohydrate metabolism, disorders 177, 560–562 carcinoid syndrome 439, 569 carcinoma cutaneous 505 squamous cell, osseous infiltration 499 carpal bones (carpus) arthrodesis see arthrodesis CT 68, 70 cysts, idiopathic 479 dynamic MRI 83 fractures, non-scaphoid 244–258 children 257 combined non-scaphoid fractures 254, 256 differential diagnosis 257 general information on diagnostic imaging 244–245 general information pathoanatomy and clinical symptoms 244 scaphoid fracture combined with 225 therapeutic options 257 see also dislocation fractures and specific bones fractures, scaphoid see scaphoid trauma infectious arthritis 452, 455 instability see instability joint compartments see compartments in Madelung’s deformity 174 morphometry and function 125–130 radial and ulnar inclination see radial inclination; ulnar inclination

osteoarthritis, with scaphoid non-union 232, 235, 236 osteoid osteoma see osteoid osteoma osteolysis, idiopathic 573 osteonecrosis see osteonecrosis radiographs see radiography rheumatoid arthritis, MRI 87, 425 stability see stability translocations 288–291 ulnar 104, 288–290, 291 trauma CT 72, 217–292 dislocations see dislocation; dislocation fractures distal radius fracture-associated 191–192 fractures see dislocation fractures; fractures (subheading above) MRI 85 postsurgical radiographs 137 scintigraphy 50 variant anatomy accessory bones see accessory carpal bones coalescence/fusions/synostoses 151, 167 division 153 notches and depressions 154, 429 carpal bossing see “humpback” deformity carpal collapse in destructive osteoarthropathy of wrist 397 osteoarthritis associated with 321–323 scaphoid non-union advanced collapse (SNAC) 232, 234, 321 scapholunate advanced collapse see SLAC wrist syringomyelia 406 carpal humps see “humpback” deformity carpal joints, osteoarthritis 319–320 carpal ligaments 93–113 anatomy 98–104 classification 98 diagnostic imaging 104–112 MRI 89, 99, 104–112 other methods 112 injury 198 in Mayfield’s categories of perilunate instability 270 pathoanatomical principles 104 rheumatoid arthritis, MRI 426 carpal stenosis, osseous 525, 526, 527 carpal tunnel anatomy 522–523 MRI 90–91 radiography 8 synovial sarcoma 512 carpal tunnel syndrome 522–535 chronic 528, 568 diagnostic imaging 526–528 fibro-ostitis associated with 333 hydroxyapatite deposits 399 postsurgical findings 530 therapeutic options 530 Carpenter syndrome 166, 552 carpometacarpal hump see “humpback” deformity carpometacarpal joint dislocations and fracture-dislocations 293–297, 300

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diagnostic imaging 293–294 differential diagnosis 296 pathoanatomy and clinical symptoms 293 patterns/classification 294 first, arthrography 27 osteoarthritis 319–320 carpotarsal osteolysis syndrome 176, 570 carpotrapezial joint arthrography, indications 28 carpus see carpal bones cartilage articular see articular cartilage bone tumors derived from 487–491 ultrasound, normal findings 58 see also triangular fibrocartilage catheter angiography 40–41 access for 40 indications 44 risks 41 causalgia 377 cavernous hemangioma 494 cavernous lymphangioma 515 celiac disease 439 central polydactyly 169 central ray deficiency 161 cerebrohepatorenal syndrome 555 Chamay’s translation index 127, 290 Charcot osteoarthropathy 406, 566, 585 Chauffeur’s fracture 182, 183, 265 children carpal fractures 257 scaphoid 219 finger injury/fracture 305, 310 hyperthyroidism 387 hypothyroidism 386, 386–387 lead osteopathy 390 leukemia 574 physical abuse (battered-child syndrome) 578 scintigraphic peculiarities 52–53 see also infants; newborns and entries under juvenile chondroarthropathy 317 chondroblastoma 490 chondrocalcinosis (calcium pyrophosphate deposition disease; pseudogout; pyrophosphate arthropathy) 319, 331, 482, 565, 571, 585 diagnostic imaging 326–327, 396–397 differential diagnosis 397, 565, 571, 585 pathoanatomy and clinical symptoms 395 therapeutic options 397 tumorous 397, 585 chondrodysplasia metaphyseal 557 with thymolymphopenia 557 progressive pseudorheumatoid 558 chondrodysplasia punctata type I 556 type II, rhizomelic form 556 chondrodystrophia fetalis 556 chondroectodermal dysplasia (Ellis–van Creveld syndrome) 169, 556 chondrogenous tumors of bone 487–491 chondrohypoplasia 557 chondroma (enchondroma) 312, 487–488, 568 periosteal 488, 586

Index

see also Maffucci syndrome; Ollier disease chondromatosis (enchondromatosis) 175, 487, 558, 573 synovial 414 chondromyxoid fibroma 490 chondrosarcoma 490–491, 568 Churg–Strauss syndrome 541 cineradiography 20–21 carpal instability 272 lunotriquetral dissociation 283 midcarpal instability 288 scapholunate dissociation 278 CISS sequence 78 clasp thumb 164 “cleft hand” 161, 166 cleidocranial dysostosis 570 clinodactyly 163–164 clotting factor deficiencies 407 “clubhand” radial 161 ulnar 161 coagulation factor deficiencies 407 cold injury (frostbite) 568 Cole’s method 192 colitis, ulcerative 432, 439 collagenoses, systemic (connective tissue diseases) 444–450, 540–541 algodystrophy vs 381 vascular disease 540–541, 588 collateral bands, MRI 95 collateral ligaments, carpal anatomy 103–104 injuries 346–349 avulsion 210 MRI 109 see also radial collateral ligament; ulnar collateral ligament Colles’ fracture 182, 183 colour-coded duplex ultrasonography 56 communicating defects (wrist arthrography) 25 compartments (joint spaces of wrist/carpus) 23 large 23 arthrography 24–26 multicompartment arthrography 4–5 small 23 arthrography 27 ulnocarpal, lesions see ulnocarpal compartment compartments (muscle), MRI 88 complex regional pain syndrome (sympathetic reflex dystrophy; Sudek disease) type I see algodystrophy type II 377 compression fractures distal radius 183 hamate 252 compression neuropathies median nerve see carpal tunnel syndrome ulnar nerve see ulnar tunnel syndrome ultrasound examination 61 computation, image CT 66 soft-tissue infections 468 computed tomography 63–74

arthrography followed immediately by 70–71 artifacts 65 bone tumors 72, 487 chondrosarcoma 491 giant-cell tumor 493 hemangioma 494 osteoid osteoma 491 osteosarcoma 493 carpal dislocations/fracture-dislocations 261 carpal fractures (non-scaphoid) 244 capitate 252 combined 256 hamate 252–253 lunate 249 pisiform 249 trapezium 255 triquetrum 248 carpal instability 273 midcarpal instability 288 scapholunate dissociation 275 carpal tunnel syndrome 527 carpometacarpal dislocations/fracturedislocations 294 crystal-induced osteoarthropathies and related diseases gout 394 hydroxyapatite deposits 399 pseudogout 396 distal radius fracture 192–194 associated distal radioulnar joint injury 198 malunion and nonunion 196 enthesopathy 329 examination technique 65–66 fingers (incl. injuries) 65, 72, 304 ganglion cyst 507 intraosseous 498 general principles 63 hemophilic osteoarthropathy 407 image postprocessing from volume datasets 67–69 indications 72, 73 infectious arthritis 452 lunate osteonecrosis 72, 355–356 metacarpal fractures 298–299 muscle injuries 348 normal anatomy 70 osteoarthritis 72, 317 osteomyelitis 460 phalangeal 464 parameters 64 quantitative, osteoporosis 369 rheumatoid arthritis 424 scaphoid fracture 72, 220, 222, 222–225 scaphoid fracture non-union 72, 225, 234–236 postsurgical 241 seronegative spondylarthropathies 433 soft-tissue infections palmar deep space 472 tendon sheath 473 soft-tissue tumors 503 aggressive fibromatosis 510 fibroma 508 ganglion cyst 507 giant-cell tumor of tendon sheath 509

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lipoma 507 neurogenic 517 sarcoma 511 spiral see spiral CT synovial chondromatosis 414 tendinosis and tenosynovitis 340 tendon rupture 341 trapezoid 255 triangular fibrocartilage complex 121, 213 ulnar tunnel syndrome 533, 534 computed tomography arthrography 24, 25, 28, 70–71 osteoarthritis 317 technical procedure 70–71 congenital anomalies see malformations and deformities connective tissue diseases see collagenoses connective tissue origin bone tumors of 493–494 soft-tissue tumors of 505–511 Conradi–Hünermann syndrome 556 constriction-ring syndrome 160, 172–173 constructive interference in the steady state 78 continuous-wave ultrasound 56 contrast agents (and contrast-enhanced imaging) angiography 40–41 risk associated with 41 MR angiography 42–43, 82 triangular fibrocartilage complex lesions 203, 206 MR arthrography 82 MRI 81–83, 84 carpal instability 273, 279, 282, 284 lunate osteonecrosis 358, 361 nephrogenic systemic fibrosis 83 rheumatoid arthritis 427 soft-tissue tumor 503 triangular fibrocartilage complex 117 ultrasonography 56 contrast resolution digital radiography 13 ultrasonography 57 convoluted projection in CT 63 copper metabolism, disorders 177, 401, 561 Cornelia de Lange syndrome 172, 174, 552 “corner sign” 239 coronal multiplanar reconstruction images 67 cortical bone lesions 576–579 corticoid osteopathy 389 cranial (giant-cell) arteritis 541 cranio-carpotarsal dystrophy 553 craniofacial dysostosis (Apert–Crouzon syndrome) 552 craniometaphyseal dysplasia 558 CREST syndrome 446 cretinism (childhood hypothyroidism) 386, 386–387 Crohn disease 432, 439 Crouzon (Apert–Crouzon) syndrome 552 cruciate pulleys 342 crystal-induced arthropathies 331, 392–403 calcium deposits see calcium deposits in carpal tunnel syndrome etiology 525 CT osteoabsorptiometry 72–73 “cup-and-saucer” deformity 422

593

594

Index

cutaneous disorders/lesions see arthrodermatitis; pachydermoperiostosis and entries under dermato-; skin cutis see arthrodermatitis; pachydermoperiostosis; skin cyst(s) bone see bone cysts ganglion see ganglion mucoid 318 resorption, scaphoid non-union 230, 232, 233, 235 sarcoid 404 cystic lymphangioma 515

D dactylitis Reiter syndrome 436 sarcoid 404 de Quervain disease 336, 338 de Quervain (trans-scaphoid perilunate) fracture-dislocation 260, 263, 264 debridement, triangular fibrocartilage complex 34 deformities joint, in rheumatoid arthritis 423 skeletal 174–178 definition 173 soft-tissue tumor vs 502 see also malformations and deformities degeneration (and degenerative lesions) 315–382 communicating defects due to 26 in distal radius fracture, pre-existing 192 enthesopathy associated with 330 lunotriquetral dissociation due to 282 tendon, ultrasonography 341 triangular fibrocartilage complex see triangular fibrocartilage complex delta phalanx 163 denervation, muscle 348, 349 density resolution in CT 64 depth compensation, B-mode ultrasonography 55 dermal hypoplasia, focal 553 dermatomyositis 448–449, 541, 564, 567, 577, 587 dermatoses, osteoarthropathies associated with 440 desmoplastic fibroma 493 DESS sequence 78 destructive osteoarthropathy of wrist 397 destructive polyarthritis in scleroderma 447 development see growth and development diabetes mellitus 576 enthesopathy 330 lipoatrophic 581 neurogenic osteoarthropathy 406, 568 dialysis-associated amyloid osteoarthropathy 408, 498 diaphyseal dysplasia, progressive 558, 577, 580 diastrophic dwarfism 557 differentiation of parts, failure 162–167 diffuse idiopathic skeletal hyperostosis (DISH) 330, 578, 581 digital luminescence radiography 2, 13–14 digital radiography (in general) 13–15 cineradiography using 20

digital subtraction angiography (DSA) 15, 41, 536 endangitis obliterans 538–539 image acquisition 41 indications for MR angiography vs 43–44 peripheral embolism 537 peripheral vascular disease 536 Raynaud disease 540 scleroderma 540 thenar/hypothenar-hammer syndrome 542 traumatic lesions 541, 542, 543–544 variant anatomy 39 digital subtraction arthrography 25 Dihlmann classification of enthesopathy 329 concept of seronegative spondylarthropathies 431 direct signs of arthritis 432 1,25-dihydrocholecalciferol) see vitamin D direct radiographic magnification (DIMA) technique 16, 17 direct radiography with flat detectors 2, 14–15 disappearing bone syndrome 573 DISH syndrome (diffuse idiopathic skeletal hyperostosis) 330, 578, 581 dislocation(s)/displacement carpal 259–268 classification 260 pathoanatomy and clinical symptoms 259–260 therapeutic options 137, 268 carpometacarpal see carpometacarpal joint differential diagnosis 268 distal forearm 182–194, 197–198 classification 185 diagnostic imaging 198 fingers 305, 310 patterns of injury 261–267 radiocarpal 286 scaphoid fracture fragment 222, 224, 236 dislocation fractures (fracture-dislocations) carpal 259–261, 267 differential diagnosis 268 pathoanatomy and clinical symptoms 259–260 therapeutic options 137, 268 trapezium 254 carpometacarpal see carpometacarpal joint finger 312 Galeazzi’s 182, 183, 197, 198 metacarpal base II–V 300 displacement see dislocation dissociative carpal instability 270, 271, 274–285 distractions, soft-tissue and callus 141 documentation see recording and documentation dolichophalangeal triphalangy type 169 Doppler ultrasonography 56 dorsal avulsion injury, triquetrum 246 dorsal carpometacarpal dislocations 294 dorsal carpometacarpal fracture-dislocations 294 dorsal intercalated (dorsiflexed intercalated) segment instability (DISI) 232, 271, 274, 276, 278, 289

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dorsal phalanx fractures 308, 309 dorsal radioulnar ligament see radioulnar ligament dorsal translocation of carpus 290–291 dorsal V-shaped carpal ligaments 99 anatomy 103 MRI 108 dorsovolar radiograph view of wrist 4 dorsum of hand arterial anatomy 40 ultrasonography 58 dose CT 65–66 scintigraphy, children 52 “double-line” sign 107 scaphoid 107, 237 Down syndrome 552 drug-induced disorders osteopathies 389–390 therapeutic options 391 Raynaud phenomena 589 see also toxins drug therapy ankylosing spondylitis 438 dermatoses-associated osteoarthropathies 440 enteropathic arthritis 440 gout 394 osteoporosis 370–371 polymyositis and dermatomyositis 449 reactive arthritis 438 poststreptococcal 443 rheumatoid arthritis 429 scleroderma 448 systemic lupus erythematosus 444 see also specific (types of) drugs dual-echo steady-state technique 78 dual-photon absorptiometry algodystrophy 379 osteoporosis 368 dual X-ray absorptiometry 368–369 duplex ultrasonography 56 duplications skeletal 168–169 tendon 155 dwarfism diastrophic 557 metatropic 557 Dyggve–Melchior–Clausen syndrome 557 dynamic carpal instability 131, 269 lunotriquetral dissociation 282 midcarpal instability 286, 287–288, 289 dynamic MRI of carpus 83 in instability 273 dyschondrosteosis (Leri–Weill syndrome/ disease) 175, 558 dysencephalia splanchnocystica 554 dysosteosclerosis 558 dysostosis (skeletal) 174–175 cleidocranial 570 craniofacial (Apert–Crouzon syndrome) 552 dysostosis epiphysaria multiplex 556 dysostosis multiplex 177–178 dysplasia fibrous 483, 558, 572, 573 skeletal 175–176, 556–559, 580 dysplasia epiphysealis hemimelica 489, 584 dystrophic phase of algodystrophy 377–379, 379

Index

E Eaton and Littler’s stages of trapeziometacarpal joint osteoarthritis 320 echo-planar imaging sequences 79 ectrodactyly (constriction-ring syndrome) 160, 172–173 edema, carpal tunnel syndrome etiology 523 Edward syndrome 553 Ehlers–Danlos syndrome 569 electrical injuries 568, 578 Ellis–van Creveld syndrome 169, 556 embolism, peripheral 537 enchondroma see chondroma enchondromatosis see chondromatosis endangiitis obliterans 538–539 endocrine diseases 572 enthesopathy 330–331 osteopathies 384–387 Raynaud phenomena 589 endosteal hyperostosis, van Buchem’s 175, 580 endothelium bone tumor originating from 494 soft-tissue tumor originating from 513–515 Engelmann–Camurati disease 558, 577, 580 enostoma see bone island enteropathic arthropathies 432, 439–440, 563 enthesopathy 329–334, 571 bone cysts 478, 479–481 diagnostic imaging 329 differential diagnosis 332, 571 pathoanatomy and clinical symptoms 329 therapeutic options 333 epidermal (epithelial/epithelioid) cyst 568 inclusion cyst 504 intraosseous 499 epidermolysis bullosa 569 epiphysiolysis 310 epiphysis 550 acquired lesions 550 developmental lesions 168, 550 dysplasias 489, 556 fractures classification 186, 310 distal radius 188 epithelial/epithelioid cyst see epidermal cyst epithelioid sarcoma 511 erosions arthritic 481 rheumatoid arthritis 421–422 systemic lupus erythematosus 445 erosive osteoarthritis 325, 566 erythema multiforme exudativum (Stevens–Johnson syndrome) 441, 558 Ewing sarcoma 496, 579 exostoses cartilaginous 489, 578 periosteal hyperostoses resembling 578 extension (wrist) 127–128 lunate, in scapholunate dissociation 278 radiographs in 10 triquetrum in dorsal extension in lunotriquetral dissociation 283 see also hyperextension injury extensor(s) (in general), MRI 89

extensor carpi radialis brevis muscle, tenosynovitis 336 extensor carpi radialis longus tendon rupture 341 tenosynovitis 336 variant anatomy 155 extensor carpi ulnaris tendon (and tendon sheath) anatomy 116 variant 155 MRI 91, 120 tenosynovitis 336–338 extensor digiti minimi tendon MRI 91 tenosynovitis 336 extensor digitorum brevis manus 156 extensor digitorum tendon MRI 91, 342 tear 342 tenosynovitis 336 extensor indicis (proprius) tendon MRI 91 tenosynovitis 336 extensor pollicis brevis, intersection syndrome of abductor pollicis longus and 336 extensor pollicis brevis tendon, MRI 91 extensor pollicis longus tendon MRI 91 in rheumatoid arthritis, rupture 424, 426–427 tenosynovitis 336 extensor retinaculum anatomy 102 MRI 112 extensor tendons (in general) avulsion lesion 308 rheumatoid arthritis, rupture 424, 426–427 tendinosis and tenosynovitis 336–338 ultrasound abnormal findings 61 normal findings 58 extra-articular slingshot ligaments 123 extrinsic carpal ligaments anatomy 101–104 MRI 108–112

F facial diplegia, congenital 554 factor VIII/IX/XI deficiencies 407 false aneurysm (pseudoaneurysm) 543–544 ulnar tunnel syndrome 534 familial exostosis disease 489 familial Mediterranean fever 432, 440, 563 Fanconi anemia 553 fasciitis, parosseal 578 fast field echo see GRASS fast imaging with steady procession (FISP) sequence 78 fast low angle shot see FLASH fast SPGR (fast spoiled GRASS) 79 fast spin echo (FSE) 75, 76 fast T1-weighted three-dimensional FLASH 78 fat saturation 77, 80–81 fat-stripe sign, scaphoid 221, 222 fatty tissue, ultrasound, normal findings 58 Felty syndrome 420, 562

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femoral artery access for catheter angiography 40 Fenton’s injury/syndrome 251, 266 Fernandez classification 183–186 FFE see FLASH; GRASS fibroblastic myxo-inflammatory sarcoma 512 fibrodysplasia, progressive ossifying 332 fibrogenesis imperfecta ossium 580 fibrolipoma, intraneural 518 fibroma 508 chondromyxoid 490 desmoplastic 493 nonossifying 493 fibromatosis, aggressive 510 fibro-osseous junction, diseases of see enthesopathy fibro-ostitis 329, 330–331 rheumatoid arthritis 332, 434 fibro-ostosis 329, 332, 436 fibrosarcoma bone 494 soft-tissue 511, 587 fibrous cartilage, ultrasound, normal findings 58 fibrous dysplasia 483, 558, 572, 573 fibrous histiocytoma, malignant 494, 511 fibrovascular repair, scaphoid non-union 236 field of view MRI 84 ultrasonography, extended 57 film-screen radiography 2 finger(s) arteries 39 variants 38, 39 CT 65, 72, 304 developmental defects 160–178 injuries CT 72 diagnostic imaging 72, 304–305 differential diagnosis 312 dislocations 305, 310 fracture 304–310 fracture-dislocations 312 pathoanatomy and clinical symptoms 304 therapeutic options 312 types 305 middle (3rd), ultrasonography 61 MRI 95, 304–305 radiographs 10, 304, 306 low-kilovoltage 19 ring (4th), ultrasonography 60 trigger (incl. thumb) 164, 338 see also phalanges; thumb finger joints (phalangeal joints) 23 arthrodesis 140 arthrography 28 osteoarthritis 318–319 salvage surgery, radiography 138 finger ray deficiencies 160, 161 fingertips chronic repeated injuries 585 glomus tumor 516 infections 469 Fisk’s concept of carpal rows 130 FISP sequence 78 fixation, internal, distal radius fracture 192 FLAIR 77

595

596

Index

FLASH (fast low angle shot; spoiled GRASS; T1-FFE) 78 in MR angiography 82 turbo (turbo-FFE; fast SPGR) 79 flat detectors, direct radiography with 2, 14–15 flexion interphalangeal joint fixed in 164 scaphoid, in scapholunate dissociation 278 wrist 127–128 radiographs in 10 flexor(s) (in general), MRI 89 flexor carpi radialis tendon tendinosis and tenosynovitis 338 variant anatomy 155 flexor carpi ulnaris tendon, tendinosis and tenosynovitis 338 flexor digitorum profundus tendon avulsion lesion 308 MRI 90 flexor digitorum superficialis II, muscle belly 156 flexor digitorum superficialis tendon, MRI 90, 95 flexor pollicis longus tendon, MRI 91 flexor retinaculum in carpal tunnel syndrome as cause 526 incomplete transection 530 flexor tendons (in general) fibroma 508 MRI 90–91 tendinosis 338–340 tenosynovitis 338–340 pyogenic 470–471 thickening causing carpal tunnel syndrome 523 ultrasound abnormal findings 61 normal findings 58 fluid-attenuated inversion recovery 77 fluorosis 331, 389, 577, 581, 585 focusing, ultrasonography 57 forearm distal arterial anatomy 36 CT, indications 72 fractures see radius fracture, distal morphometry and function 123–125 pronosupination 124, 125 traumatic amputations, surgery 142 foreign-body synovitis and arthritis 413–414 forensic issues, skeletal age determination 148 Forestier disease (diffuse idiopathic skeletal hyperostosis; DISH) 330, 578, 581 formation failure (defects due to) 160–161 four corner fusion see midcarpal joint, arthrodesis, partial fracture(s) carpal bones, see also carpal bones; scaphoid CT indications 72 fingers 304–310 healing see healing metacarpal see metacarpal bones osteomyelitis following 461, 462, 464 pathologic vs non-pathologic

distal radius 198 fingers 312 perilunate dislocations with accompanying other fractures 264–265 scintigraphy 46, 48, 49, 50 determining age of injury 51 non-union 51, 240 see also specific bones not mentioned above fracture-dislocations see dislocation fractures (fracture-dislocations) frambesia 579 François syndrome (osteolysis carpotarsalis progressiva; carpotarsal osteolysis syndrome) 176, 570 Freeman–Sheldon syndrome 553 friction syndrome of extensor pollicis brevis and abductor pollicis longus 336 frontal angle of radius 123 frontometaphyseal dysplasia 558 frostbite 568 Frykman classification of distal radius fractures 187 fucosidosis 178 fungal arthritis 456, 564

G gadolinium chelates 81 in lunate osteonecrosis 358 MR angiography 42–43 triangular fibrocartilage complex lesions 203 MR arthrography 82 in nephrogenic systemic fibrosis 83 Galeazzi’s fracture-dislocation 182, 183, 197, 198 gamekeeper’s thumb 344–348 ganglion/ganglion cyst 505–507 carpal tunnel syndrome 525, 528 diagnostic imaging 505–507 MRI see magnetic resonance imaging intraosseous 362, 479, 498, 571 pathoanatomy and clinical symptoms 505 ulnar tunnel syndrome 534 gangrenous infection 474 Gardner syndrome 578, 580 Garré chronic sclerosing osteomyelitis 464 gastrointestinal disease, arthritis associated with (enteropathic arthritis) 432, 439–440, 563 Gaucher disease 483, 561, 572 Gelberman’s method of ulnar variation determination 124 generalized autocalibrating partially parallel acquisition 81 genetic diseases and factors clotting defects 407 hemoglobin defects 409, 576 malformations 158 systemic disorders 572 giant-cell arteritis 541 giant-cell granuloma, reparative 498 giant-cell tumor of bone 493, 509 of tendon sheath (pigmented villonodular synovitis; xanthoma) 498, 509, 586 glomus tumor 515, 568

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glucocerebroside lipidosis (Gaucher disease) 483, 561, 572 Goltz syndrome 553 gonadal exposure, skeletal scintigraphy 47 gonococcal arthritis 455, 563 Gorham–Stout osteolysis syndrome 573 Gorlin syndrome 554, 572 gout (gouty arthritis; hyperuricemia; urate arthropathy) 319, 392–394, 482, 563, 571, 574, 585 diagnostic imaging 392–394 differential diagnosis 394, 563, 571, (MRI) 574, 585 pathoanatomy and clinical symptoms 392 therapeutic options 394 gradient echo (GRE) technique 75, 77–79 carpal ligaments 105 in phase and out of phase 81 gradient-recalled acquisition in steady state see GRASS granuloma, reparative giant-cell 498 granulomatosis, Wegener 449, 541, 563 GRAPPA 81 GRASS (gradient-recalled acquisition in steady state; fast field echo/FFE; fast imaging with steady procession/FISP) 78 spoiled see FLASH greenstick fracture of distal radius 182, 183, 186 Greulich and Pyle atlas 148–149 gripping ball, radiograph 9 Groedel (direct radiographic magnification) technique 16, 17 growth and development, skeletal 146–150 normal 146 structural defects see malformations growth hormone (somatotropin), bone growth and 366 see also acromegaly Guyon’s canal see ulnar tunnel

H Hadju–Cheney syndrome 569, 573 hamartomatous lymphangioma 515 hamate base/hook see hamulus capitate fusion with 151 chondroarthropathy of tip (hamate-tip syndrome) 317 fracture 252–254 osteoid osteoma 492 ultrasonography at level of 58, 59 hamulus (hamate base) fracture 252 osteonecrosis associated with 364 hand–foot–uterus syndrome 551 Hanhart syndrome 553 Hansen disease (leprosy) 406, 455, 563, 568, 579 Hashimoto thyroiditis 440, 563 healing and repair fractures (in general) 48 stages 46 see also malunion; non-union injury (in general), stages 336 scaphoid fracture 230–243 delayed 218, 225, 231 monitoring of course 223, 225 see also malunion; non-union

Index

height determination carpal 126–127 Youm’s index 126, 277 radial styloid process 124, 189–190 height prediction, final 150 helical CT see spiral CT hemangiectasia hypertrophicans (Klippel–Trenaunay syndrome) 513, 546, 553, 578 hemangioendothelioma bone 494, 573 soft-tissue 513, 584 hemangioma bone 494 soft-tissue 513 hematogenous diseases, Raynaud phenomena 588 hematogenous spread of pathogens to bone/bone marrow 461, 462–463 to joints 451 hematomas, muscle 349 hemochromatosis 319, 326–327, 400–401, 482, 565, 572, 585 hemoglobinopathies 409, 576 hemophilia osteoarthropathy 407, 565, 576, 579 periosteal hyperostoses 576 hemorrhagic cysts, posttraumatic 478, 571 hepatitis B 456 Herbenden’s nodules 318 Herbert classification 218 hereditary diseases see genetic diseases heteroglycanoses (disorders of carbohydrate metabolism) 177, 560–561 high-energy injuries to distal radius 183 high-frequency camera 20 high-resolution CT, scaphoid fracture 220 non-union 234 high-resolution MR angiography 42, 82 histiocytoma, malignant fibrous 494, 511 histiocytosis X 574 HLA and seronegative spondylarthropathies 432 Hodgkin disease 496 Hoffman–Tinel sign 517–518 Holt–Oram syndrome 553 homocystinuria 561 homogentisic acid, calcium salts, deposition (=alcaptonuria/ochronosis) 331, 401, 565, 585 hormonal disorders see endocrine diseases Hounsfield unit 64 “humpback” deformity/wrist (carpal humps/ bossing; carpometacarpal hump) 217, 221, 224, 236, 330, 489 carpometacarpal dislocations/fracturedislocation vs 296 Hunter syndrome 560 Hurler syndrome 560 Hutchinson–Gilford disease 570, 584 hydrogen nuclei see proton hydroxyapatite crystals 366 deposition disease 331, 398–400, 474, 585 carpal tunnel syndrome 526 hyperemia, reactive, fracture 46, 48 hyperextension injury 217 carpal instability 269 hyperlipidemia, hereditary, xanthomatosis 482

hyperostosis 176–177, 580–583 acquired 581 acquired hyperostosis syndrome 332 in acromegaly 384 congenital 580 diffuse idiopathic skeletal (DISH syndrome) 330, 578, 581 endosteal, van Buchem’s 175, 580 periosteal idiopathic, with hyperphosphatasia 577 resembling exostoses 578 pustular (in SAPHO syndrome) 440, 577, 581 hyperostotic osteopathy 577 hyperoxaluria (oxalosis) 402, 585 hyperparathyroidism 318, 366, 373, 386 atypical form 581 “brown tumors” (osteitis fibrosa cystica) 373, 483, 499, 574 differential diagnosis 375, 567, 572, 574, 576, 579, 581, 583, 584 primary 373, 375 secondary and tertiary 373 hyperphosphatasemia, chronic idiopathic 558 hyperphosphatasia, idiopathic periosteal hyperostosis with 577 hyperplasia bone marrow, in hemoglobinopathies 409 finger 170 hyperpronation injury carpal instability 269 distal radioulnar joint dislocation 197, 198 hyperpronation projection 6, 7, 220 hypersupination, distal radioulnar joint dislocation 197, 198 hyperthyroidism 387 therapeutic options 391 hypertrophic osteoarthropathy 411–412, 565, 576, 581 hyperuricemia see gout hypervitaminosis A (vitamin A poisoning) 576, 581 hypervitaminosis D 388–389, 576, 584 hypochondroplasia 557 hypogammaglobulinemia 440, 563 hypogonadotrophic hypogonadism 385 hypoparathyroidism 331, 386, 583, 584 primary vs secondary 386 hypophosphatasia tarda 557 hypophosphatemia 561 hypophosphatemic rickets, hereditary (=familial vitamin D-resistant rickets) 332, 371, 388, 561 hypopituitarism 384 therapeutic options 391 hypoplasia focal dermal 553 thumb 171 hypothenar region 542 angiography with blunt trauma 542 lipoma 507 MRI 95 hypothyroidism 386–387 hypovitaminoses see specific vitamins

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I image-intensifying radiography 15 imaging techniques 1–96 immobilization, therapeutic, inactivity osteoporosis see osteoporosis immunoscintigraphy infectious arthritis 452 seronegative spondylarthropathies 433 immunosuppressive drugs scleroderma 448 systemic lupus erythematosus 444 impaction syndromes, ulnocarpal 213–215, 324, 362 impingement syndromes, ulnar 324 inclusion cyst, epidermal 504 infants finger trauma 311 scintigraphy 52 skeletal age determination 148 infections bone cysts induced by 482 bone marrow see osteomyelitis focal, vs algodystrophy 381 soft-tissue see soft tissue infectious (septic) arthritis 451–457, 563 bacterial see bacterial arthritis differential diagnosis 452–453 pathoanatomy and clinical symptoms 451 pathways of infection 451 radiography see radiography inflammation phase of healing/repair 336 fractures 46 inflammation scintigraphy infectious arthritis 452 seronegative spondylarthropathies 433 inflammatory disease 418–475 skeletal, cysts in 478 see also osteomyelitis systemic (affecting hand) 418–457 fibro-ostitis 332 scintigraphy 50, 51 ultrasonography 61 inflammatory osteoarthritis 325 inherited diseases see genetic diseases injury (traumatic) see trauma instability carpal 104, 130–131, 269–292 axial 270, 271 classification 270–271 complex 270, 271 diagnostic imaging 271–273 differential diagnosis 291 dissociative 270, 271, 274–285 nondissociative 270, 271, 286–289 pathoanatomy and clinical symptoms 269–270 in scaphoid fracture (uncomplicated) 218, 222 in scaphoid fracture non-union 231, 232, 233, 234, 239 surgery see surgery definition 269 distal radioulnar joint 185 intensifying screens 2 intercarpal ligament, dorsal anatomy 102 MRI 112 interface reactions (ultrasound) 54 internal fixation, distal radius fracture 192

597

598

Index

interosseous ligaments, anatomy 98–100 interosseous muscles, MRI 93 interphalangeal joints chondrocalcinosis 396 distal arthrodesis 140 dislocations 311 osteoarthritis 318 in pollex flexus 164 proximal arthrodesis 140 fracture-dislocation 311 gouty arthritis 393 prosthesis 138 intersection syndrome of extensor pollicis brevis and abductor pollicis longus 336 intestinal lipodystrophy (Whipple disease) 432, 439 intoxication see toxins intra-articular fractures fingers 305, 306, 310 metacarpal I base region 299 radius arthroscopy (therapeutic) 34 classification 185, 187, 188 CT 192–194 intraosseous cysts epidermal cyst 499 ganglion cyst 362, 479, 498, 571 inversion recovery (IR) technique 77 short T1 (STIR) 77, 80 ionizing radiation see radiation iron oxides 82 ischemic osteonecrosis 479 hemoglobinopathies 409 systemic lupus erythematosus 444 isotope scans see scintigraphy

J Jaccoud’s arthritis 442, 443 Jaffé–Lichtenstein disease 483, 558, 572, 573 Jansen syndrome 557 Jeune syndrome 557 joint deformities in rheumatoid arthritis 423 scintigraphy, seronegative spondylarthropathies 433 see also entries under arthr-, articular and specific joints Joseph syndrome 569 Jüngling disease (osteitis multiplex cystoides) 404, 483 juvenile bone cyst 498 juvenile chronic arthritis 420, 567 HLA and 432 radiographic features of various forms 422 juvenile dermatomyositis 448 juvenile gouty arthritis 392 juvenile idiopathic osteoporosis 558

K Kapandij’s procedure 134 Kaposi sarcoma 515 kidney disease hyperparathyroidism in 373 systemic fibrosis in 83 osteopathy associated with chronic failure 366, 375, 579, 583, 584

toxicity of angiographic contrast agents 41 Kienböck disease see osteonecrosis kinky-hair syndrome 561 Kirner deformity 164 Klippel–Trenaunay syndrome 513, 546, 553, 578 Kniest syndrome 557

L lactation, skeletal scintigraphy contraindications 47 Langer–Gledion (tricho-rhino-phalangeal) syndrome syndrome 159, 553 Larsen radiographic grading of rheumatoid arthritis 428 Larsen syndrome 553 lateral radiograph view of wrist 4 Laurence–Moon–Bardet–Biedl syndrome 554 lead osteopathy 390, 391, 581 legal issues, skeletal age determination 148 leiomyoma 508 leprosy 406, 455, 563, 568, 579 Leri–Weill syndrome/disease 175, 558 Leroy’s inclusion-cell disease 561 Lesch–Nyhan syndrome 392 leukemia 496, 573 childhood 576 Lichtman and Ross classification of lunate osteonecrosis 355 Lichtman concept of oval ring of carpus 130 ligaments (in general) avulsion see avulsion carpal see carpal ligaments chondrocalcinosis 397 distal forearm (incl. radius) 123 avulsion fractures 183 triangular fibrocartilage complex 114 anatomy 116 MRI 119–120, 120–121, 205 various lesions, MRI 86–87 see also specific ligaments lipid metabolism, disorders 177, 561 lipoatrophic diabetes mellitus 581 lipodystrophy intestinal (Whipple disease) 432, 439 membranous 572 lipoid arthrodermatitis (multicentric reticulohistiocytosis) 410, 565, 569 lipoma 507, 586 periosteal 579 see also macrodystrophia lipomatosa lipomemembranous osteodysplasia 572 liposarcoma 511, 587 Lobstein’s osteogenesis imperfecta tarda 559 longitudinal arrest (of growth) 160–161 longitudinal fracture of capitate 251 low-kilovoltage techniques 3, 17–18 lumbricals, MRI 93 lunate dislocations 260 extension, in scapholunate dissociation 278 fracture 249–250, 362 non-union 362 fracture-dislocation 260 ganglion cyst 480, 481, 498 longitudinal axis determination 125

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ossification center, hereditary double anlage 362 osteonecrosis see osteonecrosis in radial inclination 128–129 shape variants 154 triquetrum fusion with 151 in ulnar inclination 129 ultrasonography at level of 60 see also capitolunate instability lunotriquetral dissociation 201, 281–285, 291 classification 281 diagnostic imaging 281–284 pathoanatomy and clinical symptoms 281–285 therapeutic options 285 lunotriquetral ligament 100 anatomy 100 defects/lesions/injury 26, 281, 283, 284 ganglion cyst originating from 481 MRI 107–108 lunotriquetral space, diastasis 283 lunula 153, 154 lupus erythematosus, systemic (SLE) 444, 540, 563, 577, 586 Lyme arthritis 456 lymphangioma 515 lymphatic vessel-derived tumors 515 lymphedema, chronic 576 lymphoma 496

M McCune–Albright syndrome 483, 484, 558 McKusick syndrome 557 McMurty’s translation index 127, 290 macrodactyly 170 macrodystrophia lipomatosa 170, 518 Madelung deformity 174, 175 Maffucci syndrome 487, 490, 546, 558, 573 “magic-angle” phenomenon 340 Magnavist 43 magnetic resonance angiography (MRA) 41–43, 78, 536 carpal ligaments 99 contrast-enhanced 42–43, 82 endangitis obliterans 538–539 indications for digital subtraction angiography vs 43–44 maximal intensity projection 43, 80 peripheral embolism 537 peripheral vascular disease 536 Raynaud disease 540 scleroderma 540 thenar/hypothenar-hammer syndrome 542 traumatic lesions 541, 542, 543–544 magnetic resonance arthrography 24, 25, 27, 28, 82 carpal instability 273 lunotriquetral dissociation 284 scapholunate dissociation 278, 280 carpal ligaments 105–106 direct 82, 105, 273 indirect 82, 105, 106, 273 osteoarthritis 317 triangular fibrocartilage complex lesions 203, 206, 208, 210–211 magnetic resonance imaging 75–96, 215 algodystrophy 380–381 amyloid osteoarthropathy 408

Index

arthritis 87 infectious 453 osteoarthritis 317 psoriatic arthritis 434 rheumatoid arthritis 424–425 basics 75 bone tumor 88, 487 chondrosarcoma 491 enchondroma 488 giant-cell tumor 494 hemangioma 494 osteochondroma 489 osteoid osteoma 491–492 osteosarcoma 493 carpal dislocations/fracture-dislocations 261 carpal fractures (non-scaphoid) 244 capitate 252 combined 256 hamate 253–254 lunate 250 trapezium 255 trapezoid 255 triquetrum 248 carpal instability 273 lunotriquetral dissociation 284 midcarpal instability 288 scapholunate dissociation 79, 279–280 carpal ligaments 89, 99, 104–112 carpal tunnel syndrome 526 carpometacarpal dislocations/fracturedislocations 294 contrast media see contrast agents crystal-induced osteoarthropathies and related diseases gout 394 hemochromatosis 400 hydroxyapatite deposits 399 pseudogout 396 distal radius fracture 194 associated distal radioulnar joint injury 198 malunion 196 dynamic, carpus 83 enthesopathy 329 fat saturation 77, 80–81 fingers and finger injuries 95, 304–305 ganglion cyst 87, 505–506, 506, 507 intraosseous 498 hemoglobinopathies 410 hemophilic osteoarthropathy 407 lunate osteonecrosis 87, 356–361, 361 metacarpal fractures 299 normal anatomy 88–95 osteomyelitis 461 hematogenous 463 phalangeal 464 tuberculous 463 parallel imaging 81 planning of examination volume 83–84 protocols 84–88 pulse sequences 75–80 quantitative, osteoporosis 370 recommendations 84 sarcoidosis 405 scaphoid fracture 85–86, 225–227 non-union 85–86 seronegative spondylarthropathies 433 soft-tissue infections 469

palmar deep space 472–473 pyogenic flexor tenosynovitis 470–471 tendon sheath 473–474 soft-tissue overuse and sports injuries anular pulley injuries 343 MCP I joint (gamekeeper’s thumb) 344 MCP II–V joints 347 muscle injuries 348 tendinosis and tenosynovitis 340 tendon rupture 341 ulnar styloid bursitis 348 soft-tissue tumors 88, 503 aggressive fibromatosis 510 cutaneous malignancy 505 epidermal cyst 504 fibroma 508 giant-cell tumor of tendon sheath 509 glomus tumor 515 hemangioma 513–514 lipoma 507 neurogenic 517 sarcoma 511 triangular fibrocartilage complex 86–87, 117–121, 202–207 tumorlike lesions aneurysmal bone cyst 497 synovial chondromatosis 414 ulnar tunnel syndrome 534 magnification radiography 3, 16–17 Majewski syndrome 556 malformation(s) and deformities 158–179, 550–551 carpal tunnel syndrome etiology 525 classification 159 definitions 158 diagnostic imaging 158 pathoanatomy and clinical symptoms 158 vascular 544 malformation syndromes 173–174, 552–555 classification 173–174 definition 158 diagnostic imaging 174 malignant tumors 511 bone 486 bone marrow-derived 496 cartilaginous (chondrosarcoma) 490–491, 568 connective tissue-derived 494 differential diagnosis 375 endothelial-derived 494 osteogenic 493 secondary see metastases incidence 486 soft-tissue connective tissue-derived 511 cutaneous origin 505 osseous infiltration 499 vascular origin 513, 515 malrotation metacarpal fracture-associated 298 radius (associated with fracture) 192, 194, 196 scaphoid see scaphoid, palmar rotation malunion distal radius fracture 195–196 radiocarpal instability with 286

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mammography films 3, 15–16 manganese chelates 81 marble-bone disease (osteopetrosis) 559, 580 Marfan syndrome 554 Marie–Strümpell disease see ankylosing spondylitis Maroteaux–Lamy syndrome 560 mastocytosis 581 Matti–Russi’s spongiosaplasty 241 maturation phase of injury repair 336 Mauclaire disease 364 maximal intensity projection CT 69 MR angiography 43, 80 Mayfield’s stages of perilunate dislocation/ instability 262, 269–270 Meckel syndrome 554 median artery, persistent 39, 155, 527 median nerve in carpal tunnel 90, 91, 523 compression syndrome see carpal tunnel syndrome fibrolipomatous infiltration 519 high division 155 MRI 90, 91 posttraumatic neuroma 519 MEDIC sequence 78 medical therapy, osteoporosis 370–371 see also drug-induced disorders; drug therapy Mediterranean fever, familial 432, 440, 563 Melnick–Needles syndrome 558 melorheostosis 177, 573, 577, 580 membranous lipodystrophy 574 meniscus homologue anatomy 116 MRI 120 Menkes syndrome 561 Merkel cell tumor 505 metabolic disorders/diseases deposits in 482 see also calcium deposits; crystalinduced arthropathies skeletal 177–178, 560–561 systemic 331, 383–415, 571–572 metabolism, bone 366 metacarpal bones aneurysmal bone cyst 497 CT 65 trauma 72 distraction 141 fractures 298–300 base of metacarpal I 299–300 base of metacarpals II–V 300 diagnostic imaging 298–302 differential diagnosis 303 head 302 pathoanatomy and clinical symptoms 298 postsurgical radiography 139 shafts 301 subcapital 301 therapeutic options 303 MRI 93 osteonecrosis of all bones (Caffey disease) 364, 578 of heads 364 radiographs in region of 10 short (brachymetacarpia) 171, 174

599

600

Index

traumatic amputation at level of, postsurgical radiograph 142 ultrasonography at level of 58, 60, 61 metacarpal index, Barnet–Nordin 367 metacarpophalangeal joint arthrography 28 chondrocalcinosis 397 in clasp thumb 164 gouty arthritis, MCP I 393 injuries 1st MCP joint 344–348 2nd–5th MCP joint 346–347 intra-articular loose body, thumb 307 osteoarthritis 319 prosthesis 138 radiographs 10 1st MCP joint 9, 393 metaphysis 551 acquired lesions 551 developmental lesions 168, 551 dysplasias 556–557, 558, 580 fractures (in general), classification 186, 310 fractures, distal radius bending 183 complications 196 fractures, fingers 310 metastases, bone 499, 568, 573, 579 scintigraphy 51 metastatic necroses of bone marrow 574 metatropic dwarfism 557 microbubbles as ultrasonographic contrast agents 56 midcarpal instability 286–288 midcarpal joint arthrodesis, partial (four corner fusion) 133 scaphoid non-union 241–242 arthrography 24, 25 indications 28 arthroscopy 33 access 31 compartment 23 dislocations 262 instability 104 osteoarthritis 362 in scaphoid non-union 236 milk-alkali syndrome 576, 584 mineral metabolism, disorders 177, 561 mirror hand 169 Möbius syndrome 554 Möller–Barlow disease (scurvy) 389, 576 Moneim’s swear-hand view 7, 276 mononucleosis, infectious 577 Morquio syndrome 560 movements, wrist 123–130 mucoid cysts 318 mucolipidosis II 561 mucopolysaccharidoses (MPS) 177, 560 multiecho data image combination 78 MultiHance 43 multiplanar reconstruction CT 66, 70 planning 67 MRI 80 carpal ligaments 105 multiple myeloma 496, 573 multislice spiral CT 63–64 carpal fracture 245 lunate osteonecrosis 355

mumps 456 muscles hematomas 349 MRI of muscle compartments 88 overuse and sports injuries 348–349 ultrasound, normal findings 58 variant anatomy/anomalies 155 carpal tunnel syndrome 527 ulnar tunnel syndrome 534 see also specific muscles mutilating form/stage psoriatic arthritis 435 scleroderma 447 seronegative polyarthritis 410 myeloma, multiple 496, 573 myositis ossificans 585 circumscripta 578 progressiva 554, 584

N Nattrass’ modified index of carpal height 126–127 necrobiotic pseudocysts 479, 571 necrosis bone see osteonecrosis metastatic, of bone marrow 574 muscle 348 needle angiography access for 40 indications 44 neonates, skeletal age determination 148 neoplasms see tumors nephrogenic systemic fibrosis 83 nephrotoxicity, angiographic contrast agents 41 nerve compression syndromes see compression neuropathies trauma, causing ulnar tunnel syndrome 533 see also denervation neural tissue leprosy 455 tumors originating from 517–519 neurinoma (schwannoma) 517–518, 586 malignant 518 ulnar tunnel syndrome 534 neurofibroma 517–518, 586 ulnar tunnel syndrome 534 neurofibromatosis type I 170, 484, 499, 572, 573, 579 neurofibrosarcoma 518 neurogenic osteoarthropathy 406, 566, 568, 575, 585 neurogenic tumors 517–519 neurologic disease, Raynaud phenomena in 588 neuroma, posttraumatic see posttraumatic lesions neuropathies, compression see compression neuropathies neurovascular bundles, MRI 88 neutral position, wrist 4 New York criteria for rheumatoid arthritis 419 newborns, skeletal age determination 148 Niemann–Pick disease 561 non-accidental injury (battered-child syndrome) 578 non-ionic contrast media, angiography 40

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non-ossifying fibroma 493 non-union of fracture distal radius 196 lunate 250, 362 scaphoid 230–243, 264, 479 CT 72, 225, 234–236 differential diagnosis 240 MRI 85–86, 236–239 nuclear medicine 240 osteoarthritis see osteoarthritis pathogenesis and clinical symptoms 230–232 posttherapeutic imaging 135, 241–242 radiography 232–234 therapeutic options 241–242 see also scaphoid non-union advanced collapse scintigraphy 51, 240 nuclear medicine see scintigraphy

O ochronosis (alcaptonuria; alkaptonuria) 331, 401, 565, 585 oculodentodigital syndrome 166, 554 oculofaciodigital (Gorlin) syndrome 554, 572 oligoarthritis types I/II 420 oligodactyly 160 oligosyndactyly 166 Ollier disease 175, 487, 490, 558, 573 opponens pollicis, MRI 91 os centrale 153, 154 os styloideum (styloid bone) 153, 330 osseous carpal stenosis 523, 524, 527 osseous reaction, secondary 502 osseous structures/tissues bone tumors derived from 491–493 MRI 89 in lunate osteonecrosis 359 scaphoid fracture affecting 225 soft-tissue tumor infiltration 499 triangular fibrocartilage complex lesions affecting 200 ossification nuclei/center lunate, hereditary double anlage 362 ultrasonography 148 osteitis 568 see also osteomyelitis osteitis deformans (Paget disease) 499, 577, 581 osteitis fibrosa cystica (”brown tumors”) 373, 483, 499, 574 osteitis multiplex cystoides (Jüngling disease) 404, 483 osteoabsorptiometry 72–73 osteoarthritis 316–328, 585 in calcium pyrophosphate deposition disease 319, 326–327, 396 cysts (subchondral) 480, 571 diagnostic imaging 316–319 arthroscopy 33 CT 72, 317 enthesopathy 330 midcarpal see midcarpal joint in scaphoid non-union 236, 321, 323 carpal 232, 235, 236 radial styloid 232, 239 in scapholunate dissociation 274, 277, 321

Index

special forms 325–327 erosive osteoarthritis 325, 566 therapeutic options 327 osteoarthropathies (combined arthropathies and osteopathies) 392–415, 565–566 crystal-induced see crystal-induced arthropathies dermatoses associated with 440 hemophilic 407, 565, 576, 579 hypertrophic 411–412, 565, 576, 581 neurogenic 406, 566, 568, 575, 585 psoriatic see psoriasis radiation-induced see radiation-induced osteoarthropathy osteoblastic osteosarcoma 579 osteoblastoma 493, 579 osteochondrodysplasia 175–176, 556–559 osteochondroma (cartilaginous exostoses) 489, 578 osteochondromatosis 585 osteoclastic hemangioma 495 osteoclastoma 493, 509 osteodensitometry see bone, density measurement osteodysplasia 559 lipomemembranous 572 osteogenesis imperfecta congenita 559 osteogenesis imperfecta tarda 559 osteoid 366 osteoid osteoma 491–493 carpal 257 scaphoid 240 cortical 578 periosteal 579 osteolysis Gorham–Stout osteolysis syndrome 573 idiopathic carpal 573 osteolysis carpotarsalis progressiva (carpotarsal osteolysis syndrome) 176, 570 osteoma, osteoid see osteoid osteoma osteomalacia 366, 371–372, 582 differential diagnosis 375, 582 osteomyelitis 460–467, 568, 571, 575, 581 acute bacterial 453 chronic 581 chronic recurrent multifocal 465, 577 CT 72 diagnostic imaging 460–462 scintigraphy see scintigraphy differential diagnosis 466, 568, 571, 575, 581 exogenous spreading 578 plasma-cell osteomyelitis 464, 571 secondary 464 special forms 464–465 therapeutic options 466 ungual 568 see also SAPHO syndrome osteomyelofibrosis 576, 581 osteonecrosis 351–364, 479, 581 capitate head 363 ischemic see ischemic osteonecrosis lunate (Kienböck disease) 263, 351–362, 479 diagnostic algorithm 361 diagnostic imaging 72, 87, 355–361 differential diagnosis 257, 362 etiogenesis 351

pathoanatomy and clinical symptoms 351–354 therapeutic decisions 354 therapeutic options 361–362 metacarpal see metacarpal bones phalangeal bases 365 radiation-induced 412, 568 scaphoid (fracture) 234 avascular 218, 231, 264, 479 scaphoid (idiopathic) 362 osteopathia striata 580 osteopathies (secondary) 178, 384–389 hyperostotic 577 renal 366, 375, 579, 583, 584 therapeutic options 391 toxic see toxins see also osteoarthropathies osteopenia (and osteopenic diseases) 366–376, 582 differential diagnosis 375, 582 pathoanatomy 366 periarticular, in rheumatoid arthritis 423 osteopetrosis 559, 580 osteopoikilosis 177, 573, 580 osteoporosis 366, 367–371, 582 diagnostic imaging 367–370 differential diagnosis 375, 379, 381, 582 etiology (other than inactivity) 367 generalized/diffuse 367 in acromegaly 384 inactivity 48 algodystrophy vs 379, 381 scaphoid non-union 234, 235 juvenile idiopathic 558 pathoanatomy and clinical symptoms 367 regional 367 therapeutic options 370–371 osteoradionecrosis 412, 568 osteosarcoma 493, 568 osteoblastic 579 paraosseous 587 osteosclerosis 576 scaphoid non-union 234, 235, 236 osteosynthesis metacarpal amputation injury 142 metacarpal fracture (subcapital) 139 scaphoid fracture 219, 224, 228 osteotomy, corrective, radius 136, 195–196, 196, 286 out-of-field beam-hardening artifacts 65 overgrowth 170 overuse injuries to soft tissues see soft tissues, overuse and sports injuries oxalosis 402, 585

P pachydermoperiostosis/ pachydermohyperostosis 332, 577 Paget disease 499, 577, 581 pain, ulnar side of wrist, differential diagnosis 215 palmar arches, arterial 37 palmar avulsion injury, triquetrum 246 palmar canal, MRI 93 palmar carpometacarpal dislocations 294 palmar carpometacarpal fracturedislocations 296 palmar deep space infections 471–473

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palmar flexed intercalated segment instability (PISI) 232, 281, 281–283, 289 palmar phalanx fractures 308, 309–310 palmar radioulnar ligament see radioulnar ligament palmar rotation of scaphoid see scaphoid palmar side of hand triangular fibrocartilage complex structure 119 ultrasonography 58 palmar support ligaments 123 palmar tilt 190 palmar translocation of carpus 290–291 palmar V-shaped carpal ligaments 99, 101–102 distal 99, 103–104 MRI 108 proximal 99, 101–102 palmaris longus, variant 156 palmaris longus tendon, MRI 91 Palmer’s classification of triangular fibrocartilage complex lesions 26, 34, 201, 210–211 panarteritis nodosa 449, 538, 561, 577 pancreatic diseases 439, 569 pannus 424, 425, 426 Papillon-Léage and Psaume disease (Gorlin syndrome) 554, 572 parallel imaging 81 parathyroid disorders see hyperparathyroidism; hypoparathyroidism parathyroid hormone 366 paronychia 469 partial-volume effect, CT 65 parvo-B19 456 Patau syndrome 552 pediatrics see children; infants; newborns perilunate dislocation (luxation) 259, 260, 261–263 pathoanatomy and clinical symptoms 259 radiography 260 postsurgical 137 perilunate fracture-dislocation 260, 264–265 postsurgical radiography 137 trans-scaphoid 260, 263, 264 perilunate instability, Mayfield’s categories 262, 269–270 periosteal lesions 576–579 chondroma 488, 586 periostitis, florid reactive 578 peripheral quantitative CT, osteoporosis 369 peripheral vascular disease (atherosclerosis) 534, 567 see also arteries, occlusive disease peritendinitis, crystal arthropathies 331 perodactyly (constriction-ring syndrome) 160, 172–173 Pfeiffer syndrome 552 phalanges developmental defects affecting 160–178 epidermal/epithelial cysts 504 fractures 306, 308–310 base of distal phalanx 308, 309–310 base of middle phalanx 309–310 surgery 139 tuberosity of distal phalanx 306 joints see finger joints

601

602

Index

osteomyelitis 464 osteonecrosis of bases 365 tumors chondrosarcoma 491 enchondroma 488 osteochondroma 490 osteoid osteoma 492 phalangoepiphyseal dysplasia, angle-shaped 159 pharmacoangiography 41 phenylketonuria 561 phlebectasia, genuine diffuse 545 phlebography 41 phosphate metabolism, disorders 177, 561 physical child abuse (battered-child syndrome) 578 Pierre–Marie–Bamberger syndrome 411 pigmented villonodular synovitis (xanthoma) 498, 509, 586 pincer grip, rheumatoid arthritis 419 “pinhole” defects in wrist 25 pisiform fracture 248–249 ultrasonography at level of 58, 59 “pisiform special” 7 pisotriquetral joint arthrography 27 indications 28 chondrocalcinosis 397 osteoarthritis 320 pitch factor 63 pituitary insufficiency see hypopituitarism pixels per slice (CT) 64 plain film radiography see radiography planes of movement, carpal 127 planning arthroscopic access 31 CT images 65 multiplanar slices 67 MRI examination volume 83–84 plasma-cell myeloma (plasmacytoma) 496, 573 plasma-cell osteomyelitis 464, 571 plexiform neurofibroma 517 POEMS syndrome 332 Poirier’s space 101, 102, 267 poisoning see toxins Poland syndrome 166, 544, 554 pollex flexus 164 polyarteritis (panarteritis) nodosa 449, 540, 563, 577 polyarthritis destructive, in scleroderma 447 mutilating 410 mutilating seronegative 410 preexisting, rheumatoid arthritis appearing in 562 in rheumatoid arthritis 419 in juvenile chronic arthritis 420 polydactyly central 169 radial 168–169 short-rib polydactyly syndrome 556 polymyositis 448–449, 564, 567, 577, 587 polyostotic bone lesions 573–575, 576–578, 579 polysyndactyly 166 polytrauma radiography 3 skeletal scintigraphy 50

porphyria, congenital 569 position (patient and patient’s hand) CT 65 MRI 83 radiography of distal radius fractures 188–189 scintigraphy 45 children 52 position encoding, B-mode ultrasonography 55 postmenopausal osteoporosis 368 poststreptococcal reactive arthritis (rheumatic fever) 442–443, 563 postsurgical imaging radiography 133–143 scaphoid fracture 135, 225 vascular surgery 544 posttraumatic lesions avascular osteonecrosis see avascular osteonecrosis chondroarthropathy 317 false aneurysm 543 hemorrhagic cysts 478, 570 neuroma 518 ulnar nerve 533 osteomyelitis 461, 464 ulnar artery thrombosis 538 pregnancy, skeletal scintigraphy contraindications 47 Preisser disease 362 prestyloid recess see ulnar recess princeps pollicis artery, embolic occlusion 538 Pringle–Bourneville disease (tuberous sclerosis) 484, 494, 568, 572, 573, 578, 580 productive fibro-ostitis 332, 333 progeria 570, 584 projection in CT 63 maximal intensity 69 in MR angiography, maximal intensity 43, 80 projection radiography see radiography proliferative phase of injury repair 336 pronation, MRI of hand in 88 see also hyperpronation pronator-quadratus sign 190 pronosupination, forearm 124, 125 prostaglandin osteopathy 389, 576 prostheses joint see arthroplasty scaphoid non-union 242 ulnar head 134 protein and amino acid metabolism, disorders 177, 561 proton (in MRI) 75 density 76 pseudarthrosis, scaphoid fracture 231, 232, 239 pseudoaneurysm see false aneurysm pseudocysts necrobiotic 479, 571 resorption, scaphoid non-union 230, 232, 233, 235 pseudodeficiency rickets 371 pseudoepiphyses 158, 550 pseudogout see chondrocalcinosis pseudohypoparathyroidism 178, 331, 386, 561

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pseudopseudohypoparathyroidism 386 pseudorheumatoid chondrodysplasia, progressive 558 pseudotumors, hemophilic 407 pseudoxanthoma elasticum 569, 586 psoriasis 332 arthritis and (psoriatic osteoarthropathy) 434–436, 562, 567, 577, 586 diagnostic imaging 434 differential diagnosis 434, 562, 567, 577, 586 distribution pattern 433 HLA and 432 pathoanatomy and clinical symptoms 434 periosteal hyperostoses 577 seagull deformities 318 therapeutic options 434–436 pulse sequences (MRI) 75–80 pulsed Doppler 56 B-mode ultrasonography combined with 56 punch fracture 182, 183 pustular arthro-osteitis (SAPHO syndrome) 440, 577, 581 pyknodysostosis 569, 580 Pyle disease (metaphyseal dysplasia) 556–557, 558, 580 pyogenic flexor tenosynovitis 470–471

Q quantitative CT, osteoporosis 369 quantitative MRI, osteoporosis 370 quantitative ultrasonography, osteoporosis 370

R radial artery anatomy 36, 37 embolic occlusion 536 false aneurysm 543 radial collateral ligament anatomy 103 MRI 109, 346 rupture (MRI) 346 radial inclination 128–129 radiographs 10 radial muscle group, MRI 89 radial polydactyly 168–169 radial ray deficiency (”radial clubhand”) 161 radial shift 190 radial side of hand/wrist axial dislocation injuries 267 carpal ligaments on 101 radial soft-tissue distraction 141 radial translocation of carpus 290–291 radiation exposure (health and safety considerations) radiography 2 scintigraphy 47 radiation-induced arteriopathy 543 radiation-induced osteoarthropathy 412, 566, 578 osteonecrosis 412, 568 radiocarpal instability 286 radiocarpal joint arthrodesis 140 partial 133 arthrography 24, 25 indications 28

Index

arthroscopy 32–33 access 31 compartment 23 CT, in distal radius fracture 192, 194 dislocations 286 radiographs 4, 5 radiography (projection; plain film) 2–22 acromegaly 327, 384 algodystrophy 379 amyloid osteoarthropathy 408 ankylosing spondylitis 438 bone tumor 487 chondrosarcoma 491 enchondroma 488 giant-cell tumor 493 hemangioma 494 osteochondroma 489 osteoid osteoma 491 osteosarcoma 493 carpal (bone) 6–9 carpal arches 125 cineradiography 21 stress views see stress views carpal dislocation/fracture-dislocation 260 carpal fractures (non-scaphoid) 244 capitate 251 combined 256 hamate 252 lunate 249 pisiform 248 trapezium 254 trapezoid 255 triquetrum 248 carpal instability 271–272 capitolunate instability 288 lunotriquetral dissociation 281–283 midcarpal instability 287–288 radiocarpal instability 286 scapholunate dissociation 276–277 carpal tunnel syndrome 524 carpometacarpal dislocations/fracturedislocations 293–294 collagenoses polymyositis and dermatomyositis 448 scleroderma 448 systemic lupus erythematosus 444 crystal-induced osteoarthropathies and related diseases gout 392–394 hemochromatosis 326–327, 400 hydroxyapatite deposits 399 oxalosis 402 pseudogout 396 dermatoses-associated osteoarthropathies 440 distal radius fractures 188–189, 190–194 associated distal radioulnar joint injury 198 malunion 196 nonunion 196 postsurgical 136 enteropathic arthritis 439 enthesopathy 28 fingers see fingers general techniques 2–3 hemoglobinopathies 409 hemophilic osteoarthropathy 407 hyperparathyroidism 373

hypertrophic osteoarthropathy 411 hypothyroidism 386–387 infectious arthritis 452, 469 acute bacterial arthritis 454 tuberculous arthritis 454 lunate osteonecrosis 355, 361 metacarpal fractures 298 multicentric reticulohistiocytosis 410 osteoarthritis 316 carpal joints 320 finger joints 318 osteomyelitis 460 hematogenous 462 secondary 464 tuberculous 463 osteopenic disorders osteomalacia and rickets 371 osteoporosis 367 renal osteopathy 375 postsurgical see postsurgical imaging pseudohypoparathyroidism/ pseudopseudohypoparathyroidism 386 psoriatic arthritis 434 radiation-induced osteoarthropathy 412 reactive arthritis 437 poststreptococcal 442 Reiter syndrome 436 rheumatoid arthritis 325 classification of stages of disease 428 pattern of distribution 418 sarcoidosis 404 scaphoid fracture 220–222 non-union 232–234 scintigraphy indicated in discrepancy between symptoms and findings of 49–50 seronegative spondylarthropathies 431–433 skeletal age determination 146, 148 soft-tissue infections 468 fingertips and paronychia 469 gangrenous 474 palmar deep space 471 pyogenic flexor tenosynovitis 470 tendon sheath 473 soft-tissue overuse and sports injuries MCP I joint (gamekeeper’s thumb) 344 MCP II–V joints 346 tendinosis and tenosynovitis 340 tendon rupture 341 ulnar styloid bursitis 347 soft-tissue tumors ganglion cyst 505 giant-cell tumor of tendon sheath 509 glomus tumor 515 hemangioma 513 neurogenic 517 sarcoma 511 special examination techniques 3, 13–22 special imaging techniques 3–11 synovial chondromatosis 414 triangular fibrocartilage complex 121, 212 tumorlike lesions (bone) aneurysmal bone cyst 497 bone island 497

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ulnar tunnel syndrome 533 ulnocarpal impaction syndrome 214 radiolunate fusion 133 radiolunate ligament anatomy 99–100 MRI 108 radiolunotriquetral ligament 101 anatomy 101 arthroscopy 32 MRI 109–110 radionuclide scans see scintigraphy radiopharmaceuticals, pediatric scintigraphy 52 see also tracer radioscaphocapitate ligament anatomy 102 MRI 109 radioscaphoid ligament anatomy 99–100 MRI 108 radioscaphoid osteoarthritis in scaphoid non-union 236 radioscapholunate fusion 133 radioscapholunate ligament (Testut’s ligament) 98–99 anatomy 98–99 arthroscopy 32 MRI 108 rheumatoid arthritis 426 radiotriquetral ligament, dorsal anatomy 102 MRI 111–112 radioulnar joint (in general), ultrasonography at level of (on dorsal side) 60 radioulnar joint, distal arthrography 25 indications 28 arthroscopy 33 access 31 compartment 23 distal radius fracture-associated lesions 185, 197–198 movements 124 osteoarthritis 324 ultrasonography at level, palmar side 58, 59 radioulnar ligaments dorsal anatomy 116 MRI 119–120 injuries 117 isolated 197, 205, 324 palmar anatomy 116 MRI 119–120 radioulnar translation 124 radius angles (distal radius) 123 corrective osteotomy 136, 195–196, 196, 286 lengths relative to ulna (=ulnar variance) 124, 190 in Madelung’s deformity 174 shortening 135, 190 styloid process enostoma 497 fractures (Chauffeur’s) 182, 183, 265 height/length determination 124, 189–190

603

604

Index

osteoarthritis in scaphoid non-union 232, 239 resection in scaphoid non-union 241 tuberculosis 463 tumors 495 radius fracture, distal 104, 182–199 anatomic foundations 188–190 associated injuries 191–192, 192–194 bone remodelling 48 classification 182–188 complications 195–198, 541 malunion 195–196, 286 diagnostic imaging 190–194 malunion see malunion differential diagnosis 198 intra-articular, arthroscopic surgery 34 osteoarthritis associated with 324 osteomyelitis 461 pathoanatomy and clinical symptoms 182 perilunate dislocation combined with 265 postsurgical radiography 136 scintigraphy 46 therapeutic options 136, 192 Raynaud disease/phenomenon 539–540, 567, 588–589 secondary 540, 584, 588–589 reactive arthritis 437–438, 562 differential diagnosis 437, 562 infectious arthritis 451 HLA and 432 in leprosy 455 pathoanatomy and clinical symptoms 437 poststreptococcal (rheumatic fever) 442–443, 563 radiography see radiography therapeutic options 438 reactive hyperemia, fracture 46, 48 Recklinghausen disease (neurofibromatosis type I) 170, 484, 499, 572, 573, 579 recording and documentation systems arthrography 25 radiography 2 reflex sympathetic dystrophy see complex regional pain syndrome region-of-interest technique (skeletal scintigraphy) 45 Reiter disease/syndrome 332, 436, 562 remodelling stage of fracture healing 46, 48 renal organ see kidney repair stage of fracture healing 46 reparative giant-cell granuloma 498 resorption in fibro-ostitis 332, 333 in hyperparathyroidism 331, 373 in hyperthyroidism 387 in sarcoidosis 404 in scleroderma 447 resorption cysts/pseudocysts, scaphoid nonunion 230, 232, 233, 235 resorption zones, scaphoid non-union 230, 233, 234, 235 reticulohistiocytosis, multicentric 410, 565, 569 retinoid (vitamin A) excess/poisoning (hypervitaminosis A) 576, 581 revascularizing procedures 547 scaphoid non-union 241

rhabdomyosarcoma 511 rheumatic fever 442–443, 563 rheumatoid arthritis 418–430, 541, 562, 567, 577 course of disease 419 cystic lesions 480, 571 diagnostic imaging 420–427 “seagull” deformities 318 differential diagnosis 429, 562, 567, 577, 585 algodystrophy 381 hemochromatosis 327 seronegative spondylarthropathies 433 fibro-ostitis 332, 434 MRI 87 osteoarthritis combined with 325 pathoanatomy and clinical symptoms 418–419 periosteal hyperostoses 577 radiographic classification of stages 428 subtypes/special forms 420, 562 therapeutic options 429 vascular lesions 541 rheumatoid (rheumatic) nodules 419, 424 rhizarthrosis 319–320 rickets 366, 371–372, 388, 579, 583 vitamin D-deficiency see vitamin Ddeficiency rickets vitamin D-resistant see vitamin Dresistant rickets ring sign 234, 263, 277 Rolando’s fracture 300 rotation, forearm 125 see also malrotation Rothmund syndrome 570 rubella 456, 577 Rubinstein–Taybi syndrome 554 Russe classification 221

S sacroiliitis psoriatic arthritis 434 reactive arthritis 437 Reiter syndrome 436 saddle joint arthrography 27 Saethre–Chotzen syndrome 552 sagittal angle of radius 123 sagittal multiplanar reconstruction images 67 Saldino–Noonan syndrome 556 Salter–Harris classification of metaphyseal and epiphyseal fractures 188, 310 Sanfillipo syndrome 560 SAPHO (synovitis, acne, pustular hyperostosis, osteomyelitis) syndrome 440, 577, 581 sarcoidosis (Boeck disease) 404–405, 483 differential diagnosis 405, 569, 572, 574, 577, 581, 586 sarcoma 568 bone bone marrow-derived (Ewing’s sarcoma) 496, 579 cartilaginous/chondrogenic 490–491 connective tissue-derived 494 endothelial-derived 496 osteogenic see osteosarcoma soft-tissue 568, 587 blood vessel-derived 515

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connective tissue-derived 511 neural tissue-derived 518 ulnar tunnel syndrome 534 scaphocapitate ligament, anatomy 102 scaphoid bipartite 153, 240 bone island 240 CT 65, 67, 69 cystic lesions 240, 481 “double-line” sign 107, 237 fat-stripe sign 221, 222 flexion in scapholunate dissociation 278 longitudinal axis determination 125 osteoid osteoma 240 osteonecrosis see osteonecrosis palmar rotation/malrotation 104 and subluxation 397 quartet series/views 6, 220 in radial inclination 128 in ulnar inclination 129 ultrasonography 61 scaphoid-capitate fracture syndrome 251, 266 scaphoid non-union advanced collapse (SNAC) 232, 234, 321 scaphoid shift maneuver, Watson’s 275–276 scaphoid trauma (fracture) 217–229 capitate head fracture combined with 251, 266 childhood 219 complications 219, 230–243 non-union see non-union diagnostic imaging in acute stages 220–228 CT 72, 220, 222, 222–225 MRI 85–86, 225–227 scintigraphy 50, 222 diagnostic imaging in non-union 72, 85–86, 225, 232–240 differential diagnosis 228 pathophysiology and clinical symptoms 217–218 perilunate injuries including 264 postsurgical radiography 135, 225 therapeutic options 219, 228 scapholunate compartment, arthrography 26 scapholunate dissociation 274–280, 291, 321 calcium pyrophosphate deposition disease 396 diagnostic imaging 276–280 MRI 79, 279–280 osteoarthritis in 274, 277, 321 pathoanatomy and clinical symptoms 274–276 classification 274–276 postsurgical radiograph 137 therapeutic options 280 scapholunate ligament 100 anatomy 100 arthrography defects/lesions/injury 26, 278–279 variants 25–26 arthroscopy 32 rupture 33 CT arthrography of central perforation 71 ganglion cyst originating from 480, 481 MRI 106–107 injury/rupture 79, 273, 279–280 perilunate dislocation-associated injury 263, 270

Index

scapholunate dissociation and insufficiency/associated lesions of 274–276 scapholunate space, diastasis (Terry Thomas sign) 276, 278 scaphotrapezial coalescence 152 scaphotrapeziotrapezoid (triscaphe) joint calcium pyrophosphate deposition disease 397 dislocation 263 fusion 133 osteoarthritis 320 scaphotrapeziotrapezoid ligament, anatomy 102 Schacherl’s radiographic staging of rheumatoid arthritis 428 Scheie syndrome 560 schistosomiasis (bilharziosis) arthropathy 456 Schmid syndrome 557 Schreck’s projection 6, 7, 220 schwannoma see neurinoma scintigraphy (radionuclide scans; nuclear medicine – predominantly skeletal) 45–53 algodystrophy 379 amyloid osteoarthropathy 408 arthritis 49 infectious 452 rheumatoid 423 biological foundations 46–47 carpal fractures (non-scaphoid) 245 children, peculiarities 52–53 contraindications 47 factors influencing images 48 hemoglobinopathies 409 hypertrophic osteoarthropathy 412 indications 49–51 lunate osteonecrosis 361 osteomalacia and rickets 371 osteomyelitis 49, 51, 462 hematogenous 462 physical/technical foundations 45 sarcoidosis 405 scaphoid fracture 50, 222 non-union 240 seronegative spondylarthropathies 433 soft-tissue infections 468 three-phase see three-phase scintigraphy tumors 49, 51, 487 osteoid osteoma 492 scleroderma (progressive systemic sclerosis) 446–448, 540, 563, 567, 577 soft-tissue calcifications 447, 586 sclero-osteosis 580 sclerosing bone dysplasia, mixed 580 sclerosing osteomyelitis, Garré chronic 464 sclerosing skeletal changes, congenital 176–177 scurvy 389, 576 “seagull” deformity 318 sebaceous cyst, phalangeal 504 Seckel syndrome 554 Seldinger technique 40 Sennwald method 190 SENSE (sensitivity encoding) 81 septic arthritis see infectious arthritis seronegative arthritides 332 axial skeleton involvement see spondylarthropathies

mutilating 410 polyarthritic nonsystemic seronegative juvenile chronic arthritis 420 rare 440 seropositive juvenile chronic arthritis, polyarthritic nonsystemic 420 Servelle–Martorell arteriovenous malformation 546 Sézary syndrome 570 Sharp radiographic staging of rheumatoid arthritis 428 Sharp syndrome 446, 447 shearing fractures, distal radius 183 Shinz syndrome 569 short-rib polydactyly syndromes 556 short T1 inversion recovery (STIR) technique 77, 80 shortening distal radius 135, 190 metacarpal, assessment 298 shoulder–girdle syndromes 588 Shulman syndrome 446 sickle-cell anemia 409, 565, 574 siderophilia (primary idiopathic hemochromatosis) 319, 326–327, 400–401, 482, 565, 571, 585 signal cysts 481 signal-to-noise ratio, ultrasonography 57 silicon-induced synovitis and arthritis 413–414 silicon prosthesis, scaphoid non-union 242 Silver–Russell syndrome 555 Simmen and Huber’s surgical classification of rheumatoid arthritis 428 simultaneous acquisition of special harmonics 81 single-photon absorptiometry 367–368 single X-ray absorptiometry 368 Sjögren syndrome 420, 450, 563 skeletal dysostosis 174–175 skeletal dysplasia 175–176, 556–559, 580 skeleton age determination 146, 147–148 growth and development see growth and development maturation disturbances 146 causes 146 metabolic disorders/diseases 177–178, 560–561 scintigraphy see scintigraphy variant anatomy 151–154 skier’s thumb 344–348 skin (cutis) low-kilovoltage radiography 18 tumors derived from 504–505 see also arthrodermatitis; pachydermoperiostosis and entries under dermSLAC (scapholunate advanced collapse) wrist 274, 275, 277, 321, 397 syringomyelia 406 slice, CT planes, normal anatomy with evaluation of 70 thickness 64 slingshot ligaments, extra-articular 123 Sly syndrome 560 SMASH 81 soft tissue(s) calcifications see calcifications

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CT of soft tissue diseases 72 distractions 141 infections 468–475 diagnostic imaging 468–469 differential diagnosis 474 pathoanatomy and clinical symptoms 468 injuries overuse and sports-related see subheading below reactive hyperemia 48 low-kilovoltage radiography 18 MRI see magnetic resonance imaging overuse and sports injuries 335–350 diagnostic imaging 335 differential diagnosis 349 pathoanatomy and clinical symptoms 335 radiographic signs infectious arthritis 452 rheumatoid arthritis 420–421, 423 scleroderma 447 seronegative spondylarthropathies 432 therapeutic options 474 ultrasound abnormalities 61–62 examination procedure 58–59 normal findings 58 variant anatomy see anatomic variants soft-tissue tumors 502–521, 568, 574, 586–587 carpal tunnel syndrome with 527 diagnostic imaging 502–505 angiography see angiography MRI see magnetic resonance imaging differential diagnosis 520, 568, 574, 586–587 osseous infiltration 499 pathoanatomy and clinical symptoms 502 therapeutic options 520 ulnar tunnel syndrome 534 somatotropin see acromegaly; growth hormone sonography see ultrasonography spatial bandwidth, CT 65 spatial resolution CT 64 digital radiography 13 ultrasonography 57 spectral fat saturation 80 sphingomyelin lipidosis 561 spin echo (SE) conventional 75, 76 carpal ligaments 105 fast/turbo (FSE; TSE) 75, 76 spinal disease, Raynaud phenomena 588 spinal dysplasia 557–558 spiral (helical) CT 63–64 carpal fracture 245 carpometacarpal dislocations/fracturedislocations 294 lunate osteonecrosis 355 spoiled GRASS see FLASH spondylarthropathies, seronegative 431–441 definition 431 diagnostic imaging 431–433 spondylitis ankylosing see ankylosing spondylitis

605

606

Index

psoriatic 434 spondyloenchondrodysplasia 559 spondyloepiphyseal dysplasia, congenital 557 spongiosaplasty 241 sports, soft-tissue injuries see soft tissues, overuse and sports injuries squamous cell carcinoma, osseous infiltration 499 stability, carpal 130–131 definition 269 etiology 270 intrinsic vs extrinsic factors 269 scaphoid fracture 217 criteria 222 see also instability staphylococcal arthritis, acute 452 static carpal instability 130, 269 lunotriquetral dissociation 282 midcarpal instability 287, 289 static-dynamic midcarpal instability, combined 286, 287, (MRI) 289 Stecher’s projection 6, 7, 220 Steinbrocker’s radiographic classification of rheumatoid arthritis 428 Stener’s lesion 344, 346 stenosing tenosynovitis 336, 338 steroid-induced osteopathy 389 Stevens–Johnson syndrome 441, 561 Stickler syndrome 556 Still syndrome 420 adult 420, 562 STIR (short T1 inversion recovery technique) 77, 80 storage diseases 178, 574, 589 storage screens, digital luminescence radiography 2, 13, 14 strains 348–349 stress views arthrography 25 radiography of carpus 8–9 carpal instability 272 radiography of thumb 8–9 strontium poisoning 577, 581 styloid bone (os styloideum) 153, 330 styloid process radial see radius ulnar, radiograph 4 subchondral bone plate cystic lesions 479 in chondrocalcinosis 482 in osteoarthritis 480, 571 low-kilovoltage radiography 18 rheumatoid arthritis 422 subclavian artery embolus 535 subcutis, low-kilovoltage radiography 18 subluxation, distal radioulnar joint 197 subungual exostosis 489 subungual glomus tumor 516 Sudek disease see complex regional pain syndrome superinfections in leprosy 455 superparamagnetic iron oxides 82 supination see hypersupination; pronosupination surface-shaded display 80 surgery arthroscopic see arthroscopic surgery bone tumors 500

carpal dislocations/fracture-dislocations 137, 268 carpal instability 137 lunotriquetral dissociation 285 midcarpal instability 288 radiocarpal instability 286 scapholunate dissociation 280 ulnar translocation of carpus 290 carpal non-scaphoid fractures 257 carpal tunnel syndrome 530 chondrocalcinosis 397 distal radius fractures 136, 192 finger fractures 312 lunate osteonecrosis 361–362 MCP I joint injury (gamekeeper’s thumb) 346 MCP II–V joint injuries 347 metacarpal fractures 303 muscle injuries 349 osteoarthritis 327 osteomyelitis 466 radiography following see postsurgical imaging scaphoid fracture 228 ununited 241–242 scintigraphy in delayed convalescence following 51 soft-tissue infections 474 soft-tissue tumors 520 synovial chondromatosis 415 ulnar tunnel syndrome 535 ulnocarpal compartment lesions 215 vascular disorders 547 Swanson arthroplasty 138 swear-hand view (Moneim’s projection) 7, 276 symbrachydactyly 161, 166 sympathetic reflex dystrophy see complex regional pain syndrome symphalangy 162 syndactyly 165–167, 173, 544 synostoses (fusions), carpal 151, 167 synovial chondromatosis 414 synovial sarcoma 511, 587 synovitis foreign-body 413–414 pigmented villonodular (=xanthoma) 498, 509, 586 in rheumatoid arthritis 418, 424, 426 see also SAPHO syndrome; tenosynovitis syphilis 455, 563, 579 neurological (tabes dorsalis) 406, 568 syringomyelia 406, 568 systemic collagenoses see collagenoses systemic disease 571–572 bone cysts 478, 482–484 osteomalacia and rickets in 371 systemic fibrosis, nephrogenic 83 systemic inflammatory disease see inflammatory disease systemic lupus erythematosus (SLE) 444, 538, 563, 577, 587 systemic metabolic diseases 331, 383–415, 571–572 systemic sclerosis, progressive see scleroderma

T T score 369–370 T1-FFE see FLASH

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T1-weighted contrast 76 T2-weighted contrast 76 tabes dorsalis 406, 568 Taleisnik classification of ulnar translocation of carpus 290 concept of carpal columns 130 Tanner–Whitehouse system height prediction 150 skeletal age determination 149 technetium-99 m radiopharmaceuticals in scintigraphy 45 children 52 infectious arthritis 452 seronegative spondylarthropathies 433 temporal (giant-cell) arteritis 539 tendinosis 336–340 tendon(s) in carpal tunnel 522–523 MRI 90–91 duplications 155 low-kilovoltage radiography 18 manifold 155 rupture 341 in rheumatoid arthritis 424, 426–427 ultrasound abnormal findings 61 normal findings 58 see also specific tendons tendon sheaths giant-cell tumor (pigmented villonodular synovitis; xanthoma) 498, 509, 586 inflammation see tenosynovitis ultrasound, normal findings 58 tenosynovitis carpal tunnel syndrome due to 523, 527 overuse and sports-related 336–340 persisting, differential diagnosis 349 pyogenic flexor 470–471 in rheumatoid arthritis 423–424 tuberculous 473–474 Terry Thomas sign 276, 278 Testut’s ligament see radioscapholunate ligament Teutschländer syndrome (tumorous calcinosis) 397, 583 thalassemia 409, 565 thalidomide 158 thenar region angiography in blunt trauma 542 MRI 91 thermal injury 567–568, 578 Thiemann and Nitz atlas 149 Thiemann disease 365 Thilbièrge–Weissenback syndrome 446 thoracic-outlet syndrome 537 three-compartment arthrography 25, 28 three-dimensional CT, scapholunate dissociation 275 three-dimensional MRI techniques 79–80 carpal ligaments 105 fast T1-weighted three-dimensional FLASH 78 high-resolution MR angiography 42, 82 3D time-of-flight sequences 78 three-dimensional surface reconstruction (CT) 67–69 three-dimensional ultrasonography 57 three-phase scintigraphy 45 infectious arthritis 452

Index

rheumatoid arthritis 423 seronegative spondylarthropathies 433 thromboangitis obliterans 538–539 thromboembolism, peripheral 537 thromocytopenia and aplastic-radius syndrome 553 thumb congenitally-bent 164 duplications 168–169 fractures involving 299–300, 307 gamekeeper’s/skier’s 344–348 hypoplasia/aplasia 171 MRI 95 radiographs 10 stress views 8–9 traumatic amputation, postsurgical 142 saddle joint arthrography 27 trigger 164, 338 thymolymphopenia, metaphyseal chondrodysplasia with 557 thyreohypophyseal acropathy 557, 576 thyroid dysfunction see hyperthyroidism; hypothyroidism thyroiditis, Hashimoto/autoimmune 440, 563 time-of-flight sequences, 3D 78 time-resolved MR angiography 42, 82 tissues, spread to joints of pathogens through 451 tomography computed see computed tomography conventional 20 Touraine–Solente–Golé syndrome 411 toxins/intoxication/poisoning osteopathies 389–390, 577, 581 therapeutic options 391 Raynaud phenomena 589 see also drug-induced disorders trabecular microfracture of carpus 245 scaphoid 225–226 tracer accumulation in skeletal scintigraphy 46 children 53 maximum 48 transducer technology, B-mode ultrasonography 55 translation, radioulnar 124 translation indices, carpus 127, 290 trans-scaphoid perilunate fracturedislocation 260, 263, 264 transverse arrest (of growth) 160 transverse fracture of capitate 251 transverse magnetization in GRE sequences dephasing 78 rephasing 78 trapeziometacarpal joint osteoarthritis 319, 320 resection arthroplasty 138 thumb, extreme mobility 299 trapezium, fracture 254–255 trapezium view 8 trapezoid fracture 255 trauma (injury) 181–313, 568–569, 578 amputations due to, surgery 142 carpal see carpal bones communicating defects due to 26 CT indications 72 fingers see fingers; fingertips

lesions following see posttraumatic lesions in lunate osteonecrosis etiology 351 MRI 86–87 multiple see polytrauma neural, causing ulnar tunnel syndrome 533 non-accidental (battered-child syndrome) 578 scaphoid see scaphoid trauma skeletal scintigraphy 48, 49, 50 in delayed convalescence 51 soft-tissue see soft tissue thermal 568–569, 578 triangular fibrocartilage complex see triangular fibrocartilage complex ultrasonography 61 vascular 541–544 see also fractures and specific involved tissues or structures not mentioned above Trevor disease 489, 584 triangular fibrocartilage anatomy 114, 114–115 MRI 118–119 triangular fibrocartilage complex anatomy 102, 114–116 chondrocalcinosis 397 diagnostic imaging 117–121, 202–213 arthrography 26, 121, 207–212 arthroscopy 33, 121, 207 MRI 86–87, 117–121, 202–207 functions 114 lunotriquetral ligament lesion combined with injury of 281 peripheral components 114 triangular fibrocartilage complex lesions 89, 200–213 classification 26, 34, 201–202, 210–211 degenerative 26, 34, 116, 202, 203 arthrography 208, 209, 212 chronic 200 MRI 205–207, 210–211 degenerative–traumatic (combined) 200 diagnostic imaging see triangular fibrocartilage complex pathoanatomy and clinical symptoms 116–117, 200–201 traumatic 26, 34, 116, 117, 198, 200, 201, 202, 203 arthrography 209 in distal radius fracture 197 MRI 203, 205, 210 tricho-rhino-phalangeal syndrome 159, 551 trigger finger/thumb 164, 338 triphalangeal thumb 168–169 triquetrocapitoscaphoid ligament see arcuate ligament triquetrum dislocation 263 in dorsal extension, in lunotriquetral dissociation 283 fracture 246–248 avulsion 104, 246 children 257 lunate fusion with 151 in radial inclination 129 in ulnar inclination 129 “triquetrum special” 7

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triscaphe joint see scaphotrapeziotrapezoid joint trisomy 13 (Patau syndrome) 554 trisomy 18 (Edward syndrome) 553 trisomy 21 (Down syndrome) 552 tuberculosis 571 arthritis 454–455, 563, 579, 587 osteomyelitis 463 tendon sheath 473–474 tuberous sclerosis 484, 499, 568, 572, 573, 578, 580 tumor(s) 487–521, 568, 579 angiography see angiography bone see bone tumors in carpal tunnel syndrome etiology 523, 527 malignant see malignant tumors soft-tissue see soft-tissue tumors in ulnar tunnel syndrome etiology 533, 534 ultrasonography 61 tumorlike lesions of bone 497–499 cystic see bone cysts incidence 486 tumorous (chondro)calcinosis 397, 585 turbo-FFE 79 turbo spin echo (TSE; fast spin echo/FSE) 75, 76 Turner syndrome 555 Turret exostosis 489 two-compartment arthrography 27, 28

U ulcerative colitis 432, 439 ulna aneurysmal bone cyst 497 distal, salvage procedures 134, 140 distraction 141 lengths relative to radius (=ulnar variance) 124, 190 in Madelung’s deformity 174 osteochondroma 490 shortening 135 styloid process, radiograph 4 ulnar artery anatomy 36, 37 trauma blunt 450 thrombosis following 538 ulnar canal see ulnar tunnel ulnar collateral ligament anatomy 104, 116 of first metacarpophalangeal joint, rupture 344–348 MRI 120–121 ulnar deviation of carpus 127 ulnar impingement syndromes 324 ulnar inclination 128–129, 190 radiographs 10 ulnar nerve anatomy 532 compression neuropathy see ulnar tunnel syndrome muscle denervating-lesions 349 ulnar ray deficiency (“ulnar clubhand”) 161 ulnar recess (prestyloid recess) arthrography 26, 212 bursitis 347–348 MRI 121

607

608

Index

ulnar side of wrist axial dislocation injuries 267 pain, differential diagnosis 215 ulnar translocation of carpus 104, 288–290, 291 ulnar tunnel (Guyon’s/ulnar canal) anatomy 532 MRI 91 ulnar tunnel syndrome 532–535 diagnostic imaging 533–534 pathoanatomy and clinical symptoms 533 therapeutic options 535 ulnar variance 124, 190 negative 121, 124, 135, 201 lunate osteonecrosis and 352 positive 121, 124, 213 lunotriquetral dissociation and 281–282 ulnocarpal compartment lesions 200–216 differential diagnosis 215 impaction syndromes 213–215, 324, 362 pathoanatomy and clinical symptoms 200–201 therapeutic options 215 ulnolunate impaction syndrome 214, 362 ulnolunate ligament anatomy 101, 116 injury 117 MRI 110–111, 120 ulnolunotriquetral impaction syndrome 214 ulnopalmaris pollicis artery, false aneurysm 544 ulnotriquetral ligament anatomy 101, 116 injury 117 MRI 110–111, 120 ultrafast gradient echo sequences 79 ultrasonography 54–62 B-mode see B-mode ultrasonography carpal fractures 245 scaphoid 227 carpal tunnel syndrome 526–527 distal radius fracture 194 Doppler 56 enthesopathy 329 examination procedure 58–59 gout 394 indications 61–62 infectious arthritis 452 normal findings 58 osteomyelitis 462 physical principle 54–55 quantitative, osteoporosis 370 rheumatoid arthritis 423–424 seronegative spondylarthropathies 433 skeletal age determination 148 soft-tissue infections 468 palmar deep space 471–472 pyogenic flexor tenosynovitis 470 tendon sheath 473 soft-tissue overuse and sports injuries anular pulley injuries 342 MCP I joint (gamekeeper’s thumb) 344 MCP II–V joints 345 muscle 348 tendinosis and tenosynovitis 340

ulnar styloid bursitis 348 soft-tissue tumors 502 fibroma 508 ganglion cyst 506, 507 giant-cell tumor of tendon sheath 509 lipoma 507 neurogenic 517 sarcoma 511 synovial chondromatosis 414 technical prerequisites for hand examination 57 tendon rupture 341 ulnar tunnel syndrome 533, 535 undergrowth 171–172 ungual osteomyelitis 568 unidirectional defects in wrist 25 urate crystal arthropathy see gout urinary bladder exposure, skeletal scintigraphy 47

V V-shaped carpal ligaments 98, 101–104 dorsal see dorsal V-shaped carpal ligaments palmar see palmar V-shaped carpal ligaments vaccinia 456 van Buchem’s endosteal hyperostosis 175 van der Linden’s method 190 variant anatomy see anatomic variants variola 456 vasa nutricia 478 vascular disorders 536–548 diagnostic imaging 536 peripheral see arteries, occlusive disease; peripheral vascular disease therapeutic options 547 vasculitis syndromes 567 vascular origin, tumors of 513–515 vascularization in osteonecrosis etiology, lunate 353, 354 see also revascularizing procedures venectasia (phlebectasia), genuine diffuse 545 venography (phlebography) 41 venostasis in carpal tunnel syndrome etiology 523 VIBE sequence 79 vibration trauma, chronic 541 villonodular synovitis, pigmented (=xanthoma) 498, 509, 586 vinyl chloride exposure 568 viral arthritides 456, 564 vitamin A excess/poisoning (hypervitaminosis A) 576, 581 vitamin C deficiency 389, 576 vitamin D (1,25-dihydrocholecalciferol) 366, 371 excess (hypervitaminosis D) 388–389, 576, 584 vitamin D-deficiency rickets 371, 388 therapy 372 vitamin D-resistant rickets 371, 388 administration in vitamin D-resistant rickets 372 primary/congenital/familial/hereditary (hypophosphatemic rickets) 332, 371, 388, 561 therapeutic options 372

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volume datasets (CT), image postprocessing from 67–69 volume excitation 79–80 volume rendering CT 69 MRI 80 volumetric interpolated breath-hold examination 79 von Recklinghausen disease (neurofibromatosis type I) 170, 484, 499, 572, 573, 579 voxels 64, 70 Vrolik’s osteogenesis imperfecta congenita 559

W Waardenburg syndrome 552 water excitation technique 81 water saturation (in FLAIR) 77 Watson and Ballet’s stages of osteoarthritis in scapholunate dissociation 323 Watson scaphoid shift maneuver 275–276 Weber arteriovenous malformation 545 Wegener granulomatosis 449, 541, 563 Whipple disease 432, 439 wide-band frequency probes, ultrasonography 57 Wilson disease 319, 401 Winchester syndrome 561 “wind-blown” deformity 164 window values (CT) 64 Winiwarter–Buerger disease 538–539 Winterstein’s fracture 300 wrist arthrodesis see arthrodesis arthrography see arthrography arthroscopy see arthroscopy collapse see carpal collapse CT 67 destructive osteoarthropathy 397 “humpback” see “humpback” deformity joint compartments see compartments movements 123–130 MRI 90 pain on ulnar side, differential diagnosis 215 radiographs 3–5 low-kilovoltage 19

X X-ray absorptiometry dual 368–369 single 368 X-ray radiography see radiography xanthoma (giant-cell tumor of tendon sheath; pigmented villonodular synovitis) 498, 509, 586 xanthomatosis 482, 572

Y yaws 579 yo-yo sign 344, 346 Youm’s index of carpal height 126, 277

Z Zellweger syndrome 553