Radiological intervention of the hand and wrist

Abstract

The role of radiological guided intervention is integral in the management of patients with musculoskeletal pathologies. The key to image-guided procedures is to achieve an accurately placed intervention with minimal invasion. This review article specifically concentrates on radiological procedures of the hand and wrist using ultrasound and fluoroscopic guidance. A systematic literature review of the most recent publications relevant to image-guided intervention of the hand and wrist was conducted. During this search, it became clear that there is little consensus regarding all aspects of image-guided intervention, from the technique adopted to the dosage of injectate and the specific drugs used. The aim of this article is to formulate an evidence-based reference point which can be utilized by radiologists and to describe the most commonly employed techniques.

Figure 1.

In-plane and out-of-plane injection techniques. (a) The relative probe and needle position for an in-plane (longitudinal) injection technique. (b) Ultrasound image demonstrating an in-plane approach for injecting the thumb carpometacarpal joint. The entirety of the needle can be visualized in longitudinal section (short arrows). MC, base of thumb metacarpal; Trap, trapezium. The long arrow indicates a loose body in the osteoarthritic joint. (c) The relative probe and needle position for an out-of-plane (short axis) injection technique. (d) Ultrasound image demonstrating an out-of-plane approach. A cross-section of the needle can be seen as a hyperechoic dot (arrow). Please note a larger 21-G needle has been used in the Figure 1a and c for clarity. However, in practice as stated in the text a smaller needle is more appropriate for use in the hand and wrist.

Figure 2.

Longitudinal imaging of the thumb CMC joint for injection. (a) Patient position for an in-plane CMC joint injection. (b) Longitudinal imaging of the CMC. Note the radial artery with Doppler signal (arrows) runs in close proximity to the joint and it is important to avoid it. (c) Repositioning the probe slightly, in this case slightly dorsal to the position in b, allows safe access to the joint (arrow indicates needle position for in-plane approach). MC, thumb metacarpal; Trap, trapezium.

Figure 3.

Ultrasound image of scaphotrapeziotrapezoid joint in longitudinal section. The dot indicates the needle position for an out-of-plane injection. MC, thumb metacarpal base; Sca, scaphoid; Trap, trapezium. Arrows indicate flexor carpi radialis longus.

Figure 4.

Longitudinal imaging of the radiocarpal joint for injection. (a) Patient position for an in-plane radiocarpal joint injection. Note that the wrist is gently flexed over a support. (b) Ultrasound image of the radiocarpal joint in longitudinal section. The arrow indicates the needle position for an in-plane injection. Cap, capitate; L, lunate; R, radius.

Figure 5.

Illustration of the digital flexor pulley system; A1–5.

Figure 6.

Out-of-plane approach to A1 pulley injection. (a) Ultrasound image at the level of the A1 pulley in transverse section demonstrates the target triangle for an out-of-plane injection of the first annular pulley. The dot indicates the needle position; arrows show the A1 pulley; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; L, lumbrical; MC, metacarpal; VP, volar plate. (b) Patient position for first annular pulley injection to obtain the image in Figure 7a.

Figure 7.

Longitudinal approach to A1 pulley injection. (a) Ultrasound image demonstrates the normal appearance of the A1 pulley in longitudinal section (arrows); FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; MC, metacarpal; PP, proximal phalynx; VP, volar plate. (b) The in-plane injection in the longitudinal plane is demonstrated. The needle is shown (arrowheads) with its tip below and thickened and irregular annular pulley (arrows). MC, metacarpal; PP, proximal phalynx.

Figure 8.

Illustration of the dorsal extensor compartments of the wrist I–VI, highlighting the first extensor compartment which is affected by De Quervain's stenosing tenosynovitis. APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDL, extensor digitorum longus; EDM, extensor digitorum minimi; EI, extensor indices; EPB, extensor pollicis brevis; EPL, extensor pollicis longus.

Figure 9.

Ultrasound image of the first dorsal extensor compartment in transverse section. This patient has a septum between the tendons. The patient has De Quervain's stenosing tenosynovitis, but it only affects the compartment contacting extensor pollicis brevis (EPB). The arrows indicate the retinaculaum which shows low reflective thickening (*) in the compartment containing the EPB. APL, abductor pollicis longus; Rad, radius.

Figure 10.

Injection of first Extensor compartment for De Quervain's tenosynovitis. (a) Patient position for injection into first extensor compartment. (b) Ultrasound image of the first dorsal extensor compartment in transverse section for an in-plane injection. Note the thickened retinaculum (*). The arrows indicate the needle. APL, abductor pollicis longus; Art, radial artery; EPB, extensor pollicis brevis; Rad, radius.

Figure 11.

Normal carpal tunnel anatomy and positioning for injection. (a and b) Ultrasound image of the proximal (a) and distal (b) carpal tunnel in transverse section. Note the superficial position of the median nerve (MN) immediately deep to the retinaculum (arrowheads) and superficial to the flexor digitorum tendons (shaded area); UA, ulna artery; UN, ulna nerve. (c) Patient position for carpal tunnel injection to obtain an image in (a).

Figure 12.

Ultrasound image of the carpal tunnel in transverse section with in-plane carpal tunnel injection for carpal tunnel syndrome. The needle (arrows) has been positioned with its tip deep to the median nerve (MN). Following injection here the needle can be repositioned for further injection superficial to the nerve. Arrowheads, flexor retinaculum.

Figure 13.

Ultrasound image of the scaphotrapeziotrapezoid joint in longitudinal section. A ganglion cyst (G) is seen arising from the dorsum of the joint. Note the posterior acoustic enhancement indicating its cystic nature (arrows). Sca, scaphoid; Tra, trapezium.

Figure 14.

Injection of the radiocarpal joint under fluoroscopic guidance. The fluoroscopy image demonstrates contrast within the radiocarpal joint. The needle tip is at the proximal pole of the scaphoid (arrow).

Figure 15.

Injection of the distal radioulnar joint (DRUJ) under fluoroscopic guidance. (a) The fluoroscopy image demonstrates contrast within the DRUJ joint. Note the filling defect within the contrast within the DRUJ (arrow). (b) T₁ weighted axial MR image from the subsequent MR-arthrography study demonstrated the filling defect to represent a displaced flap of cartilage from the torn triangular fibrocartilage (arrows).

Figure 16.

Injection of the midcarpal joint under fluoroscopic guidance. Fluoroscopy image demonstrating a midcarpal joint injection. Note the presence of contrast into the scaphotrapeziotrapezoid joint (*).