Ultrasound as a Diagnostic Modality in Hand and Wrist Musculoskeletal Pathologies: A Narrative Review

Abstract

Background: Musculoskeletal ultrasonography of the hand and wrist is becoming the trend in assessing and diagnosing most hand and wrist injuries, soft-tissue mass, and occult fractures. Its advantages include ultra-high frequency probes, noninvasiveness, cost-effectiveness, lack of ionising radiation, and portability. The patients are comfortable doing this procedure in the outpatient department, and visualising the ultrasound images increases their confidence.

Conclusions: Ultrasound has a practical and dynamic real-time diagnostic capability compared to other modalities, playing an important role in hand and wrist pathologies. Apart from the diagnostic utility, it has also been beneficial in musculoskeletal intervention procedures, such as trigger finger, carpal tunnel syndrome, and various tenosynovitis. The learning curve and limited deeper penetrations are relative limitations to ultrasound usage. More dedicated training centres and modules for future generations and CT/MRI for deeper structures are always an alternative. This article reviews the role of ultrasound in hand and wrist pathologies.

Supplementary information: The online version contains supplementary material available at 10.1007/s43465-024-01206-3.

Keywords: Diagnostic modality; Effective; Hand and wrist; Ultrasound.

Fig. 1

The normal ultrasound pictures of carpal tunnel. L lunate; R radius; N median nerve; P proximal part of the median nerve; D distal part of the median nerve; C Capitate; TCL transverse carpal level

Fig. 2

Ultrasound pictures of a carpal tunnel syndrome with CSA of 0.35 cm² in the transverse axis and constriction of the median nerve in the longitudinal axis under the TCL. A 45-year-old woman with clinical features of carpal tunnel syndrome. Preoperative ultrasound shows an enlarged median nerve at the lunate level with a cross-sectional area (CSA 0.35cm²) in the transverse axis

Fig. 3

a Longitudinal images of the median artery in a 50-year-old patient with carpal tunnel syndrome. b Doppler images show the median artery. c Short (transverse axis) shows the artery (red) and the median nerve (N)

Fig. 4

A 55-year-old woman with clinical features of carpal tunnel syndrome. Preoperative ultrasound shows an enlarged median at the lunate level with a cross-sectional area (CSA 0.33 cm²) in the transverse axis. The postoperative follow-up ultrasound at 6 months showed a CSA of 0.07 cm²

Fig. 5

The transverse (short) and longitudinal (long) axis ultrasound images of a trigger finger showing thickened A1 pulley (arrows) around the flexor tendons

Fig. 6

The ultrasound image of needle (n) guided A1 pulley (p) release

Fig. 7

The ultrasound image shows the orientation of the pulley (n) to the flexor tendons and neurovascular structures (dotted circle) on both sides. This will guide the surgeon to orient the needle during the pulley release

Fig. 8

a The clinical picture shows swelling in the left thenar eminence. b, c Ultrasound shows an inhomogenous solid mass with well-defined borders within the APB muscle. d The intraoperative picture of schwannoma from the left thenar eminence which is well-encapsulated greyish-white, solid, and glistening

Fig. 9

a DeQuervain’s tenosynovitis with fusiform swelling (arrows) of the first extensor compartment tendons at the radial styloid level. b Tendon thickening, synovial thickening, and fluid (effusion) seen in the extensor tendon sheath (arrows). c The transverse view of the first extensor compartment shows a surrounding thin rim of inflammatory fluid (arrows) around the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). d The injection site (arrows) around the pretendinous fluid

Fig. 10

Clinical picture and ultrasound images showing the injection site for the right-side DeQuervains tenosynovitis in a 50-year-old women

Fig. 11

a The ECU is seen in the ulnar groove. b, c The extensor carpi ulnaris tendon sheath is uniformly thickened with effusion in the transverse and longitudinal axes (arrows). d There is increased local hypervascularity around the normal fibrillar pattern of the ECU tendon

Fig. 12

A 15-year-old girl with a soft-tissue lump on the dorsal wrist, soft in consistency, fluctuating, and tender on palpation. Ultrasound shows an anechoic, well-defined echogenic wall, an ovoid structure with a thin septum without vascularity communicating to the underlying joint space, confirming the dorsal wrist ganglion

Fig. 13

An 11-year-old boy with flexor tendon injury of 3 month duration in the left middle finger. Ultrasound shows a normal fibrillation pattern of FDP in the distal phalanx, FDS and FDP in the middle phalanx and absent tendons over the proximal phalanx (dotted lines). The proximal end (dotted circle) is seen at the MCP joint, and tendons are normal proximal to it. This helps in deciding the tendon reconstruction with a tendon graft. The location of tendons and defect length can be measured using ultrasound

Fig. 14

a Sixty-five-year-old woman with a non-traumatic flexor pollicis longus (FPL) tendon injury of thumb of 5 years. US showed the distal FPL at the interphalangeal joint (IP) level (dotted line). b The entire defect (dotted line) of the FPL tendon proximal to the IP joint is seen as a large hypoechoic area in ultrasound. c The proximal FPL (dotted line) was found at the distal forearm level as a fusiform-shaped thickened, replacing its normal course and ending with a defect distally. The gap was 12 cm. These images helped the surgeon plan the FDS ring finger tendon transfer to the FPL distal end

Fig. 15

a The extensor tendon rupture in 60-year-old rheumatoid arthritis women with the distal end at the metacarpophalangeal joint (MCP) of the ring finger. There is a significant defect in the tendon seen as a hypoechoic region with discontinuity in the tendon in ultrasound (*). b The proximal end is seen over the metacarpal shaft level with a distal tendon defect (*), confirming the rupture. This will guide the surgeon in using tendon transfer or end-side tendon suturing

Fig. 16

a The normal UCL is a homogenous fibrillar structure spanning the ulnar side of the metacarpophalangeal joint. b An ultrasound picture of the right thumb shows UCL avulsion (yellow dotted circle) from the proximal metacarpal attachment with a rent (arrow) in the mid-substance of the ligament. c Complete displaced distal tears and lack of visualisation of the UCL with retraction proximal to the MCP joint

Fig. 17

Images from a 50-year-old man with palmar fibromatosis. a Ultrasound images of the long axis of the ring finger show isoechoic (dotted circle) and hypoechoic palmar fibromatosis (arrows). b (yellow dotted circles) show hypoechoic, non-vascular, and fusiform lesions of the subcutaneous tissue. c The hypoechoic lesions are superficial to the flexor tendons and do not follow the movements of the flexor tendons. d Chronic nodules (yellow asterisk) appear hyperechoic without associated vascularity. These nodules can progress to hypoechoic cords and bands adhering to the flexor tendon margins, resulting in contractures and deformity

Fig. 18

a Clinical image of Dupuytren’s contracture involving the ring and little finger. b Hypoechoic palmar fibromatosis is seen (dotted circle) at the MCP joint. Normal palmar aponeurosis is seen proximally (arrows). c The location of fibromatosis close to the flexor tendons. d Short (transverse axis) shows the hypoechoic palmar fibromatosis close to the flexor tendons (F) at MCP joint

Fig. 19

Longitudinal view shows a normal with metacarpal base (1 MC) and trapezium (T); b mild; c moderate with osteophytes marked (arrow), and d severe with osteophytes marked (arrows)

Fig. 20

The ultrasound image shows the injection technique into the first CMC joint arthritis

Fig. 21

A 20-year-old engineering student sustained a bony ballet in his index finger (a). Ultrasound shows the avulsed distal phalanx fragment (b). After treatment, the bony mallet united (c) and was confirmed with an ultrasound image (d)

Fig. 22

A 21-year-old man sustained a cricket ball injury to his right index finger. The radiograph shows dorsal fracture subluxation of the PIP joint. Ultrasound shows the fracture displacement (arrows). The middle phalanx base was avulsed with the volar plate (VP) attached. After treatment, the fracture united, and the ultrasound showed a healed middle phalanx base and volar plate (VP). The radiograph confirmed a congruent joint