Ultrasound of Wrist Pain

Transverse anatomy illustration of the wrist at the level of the hook of hamate. 1: Extensor carpi ulnaris; 2: Extensor digiti minimi; 3: Extensor indicis and extensor digitorum; 4: Extensor carpi radialis and brevis; 5: Radial artery; 6: Extensor pollicis longus; 7: Extensor pollicis brevis; 8: Flexor carpi ulnaris; 9: Median nerve; 10: Palmaris longus; 11: Flexor retinaculum; 12: Ulnar artery and nerve; 13: Superficial and deep flexor tendons.

Transverse US image through the wrist at the level of the hook of the hamate (HH). The echogenic flexor retinaculum (FR) runs between the HH and the tubercle of the trapezium (T). The hypoechoic median nerve (MN) is situated superficially in the carpal tunnel, with the echogenic flexor tendons deep to it.

Coronal anatomical illustration of the wrist. 1: Ulnar collateral ligament; 2: Meniscus homologue; 3: Triangular fibrocartilage; 4: Lunotriquetral ligament; 5: Scapholunate ligament.

Normal ultrasound image of the TFC. Longitudinal, paracoronal image at the ulnar aspect of the wrist shows the normal TFC (straight arrow), distal to the ulnar styloid (UST) and proximal to the triquetral (TRI) bone. The TFC is identified deep to the ECU (curved arrow).

Transverse US images through the dorsum of the wrist at the level of the LT and at the level of the distal radioulnar joint. EPL is ulnar to the LT and the ECRB and ECRL are radial to LT (A). Extensor digitorum communis (EDC) is situated between the EPL and the DRUJ, and the EDM is dorsal to the DRUJ (B). DRUJ = distal radioulnar joint.

Normal transverse ultrasound images of the SLL (A) and the LTL (B). The black arrow in (A) indicates the SLL, bridging between the lunate (L) and scaphoid (S). The white arrow in (B) indicates the normal LTL in the same patient positioned between the lunate (L) and the triquetrum (T).

A 48-year-old woman with nodular tendonosis of the EPL with history of previous radius fracture. Longitudinal image of the wrist at the level of LT shows focal hypoechoic region in the deep portion of the tendon (between calipers).

A 45-year-old woman with severe De Quervain's disease. Transverse (A and B) and longitudinal (C and D) images through the first extensor compartment demonstrates hypoechoic active vascular tenosynovitis within the tendon sheath (arrow in C and D). Transverse images demonstrate the hypoechoic area (arrow in A) between the two tendons, suggesting presence of a septum. There is also increased vascularity with the tendon (B) suggestive of active tendonitis. (Color version of figure is available online.)

A 50-year-old woman with longstanding RA with partial tear of extensor tendon in compartment 4. Longitudinal (A) and transverse (B) images at the level of the LT demonstrate focal fluid-filled area (arrows) within the extensor tendon in keeping with a partial tear.

A 35-year-old woman with severe idiopathic CTS in the right wrist. Transverse images of the right wrist at the level of the pisiform (A and B) show increased CSA (36 mm²) in (A) and increased palmar bowing of the FR in (B). Longitudinal image (C) of the symptomatic right wrist shows the swelling of the median nerve (MN) compared to the normal asymptomatic left wrist in (D). White arrow in (A) indicates the ulnar nerve in the Guyon's canal and black arrows in (B) point to the FR.

A 43-year-old woman with longstanding RhA who developed symptoms of CTS. Axial US carpal tunnel demonstrates enlarged median nerve (arrow) with synovial thickening flexor synovial sheath with prominent flow within on power Doppler. Symptoms of CTS relieved posttreatment synovitis. (Color version of figure is available online.)

A 65-year-old man with proven schwannoma of the ulnar nerve in the Guyon's canal. Transverse US image (A) shows normal Guyon's canal with ulnar nerve (UN) and relationship to ulnar artery (UA) and flexor carpi ulnaris (FCU). (B) A well-defined, hypoechoic soft-tissue mass with posterior acoustic enhancement (white arrow), lateral to the pisiform (P) with internal vascularity on Doppler (not shown).

A 45-year-old man with TFC tear of right wrist confirmed on MR arthrogram (not shown). Longitudinal ultrasound of the symptomatic right wrist at the level of the TFC demonstrates focal decreased echogenicity (arrow) in keeping with absence of a portion of the structure. Compare with the normal echogenic TFC (Fig 4). TQM = triquetrum; DU = distal ulna.

A 42-year-old man with dorsal SLL tear of the left wrist confirmed on arthrogram (not shown). Transverse image dorsal left wrist shows the absent SLL and fluid in the scapholunate space (arrows). Compare with the normal SLL with compact fibrillar echotexture (Fig 6A).

LTL tear confirmed on arthrogram with contrast injected into the midcarpal joint space (not shown). Transverse images (A and B) at the level of the lunate (L) and triquetral (T) bones show the tear of the LTL with disruption of the normal hyperechoic linear structure and fluid filling the interval (arrows in A and B).

A 41-year-old woman with RA. Longitudinal images (A and B) through the mid dorsum of the wrist show proliferative synovitis/pannus as hypoechoic, soft tissue (curved arrow in B), and distension of the dorsal recess of the joint (straight arrow). Power Doppler shows flow in the pannus (A) indicating active synovitis.

A 26-year-old woman with RA. Longitudinal image shows multiple small erosions (white arrows) medial to the border of the distal ulna. Curved arrow points to the ECU with distension sheath with hypoechoic soft tissue in keeping with tenosynovitis.

A 40-year-old woman with dorsal wrist ganglion. Axial ultrasound dorsal aspect wrist of a well-defined heterogeneous hypoechoic mass pre- (A) and post- (B) compression. No flow on power Doppler, associated with a scapholunate tear (not shown). (C) Pathological specimen. (Color version of figure is available online.)

Giant cell tumor: Sagittal ultrasound of the volar wrist in a 24-year-old man presenting with mild swelling and hand discomfort for 1 year. US demonstrates localized tendon sheath distension with soft tissue. Mild internal flow noted on power Doppler (not shown). Remaining flexor tendon sheaths were normal. Confirmed on pathology as giant cell tumor flexor tendon sheath.

Hemangioma: Well-defined soft-tissue lesion presenting as an asymptomatic soft-tissue mass on the volar aspect of the wrist in a 19-year-old man. (A) On US lesion (arrow) is inhomogenous iso/hyperechoic, partially compressible (B), with increased internal flow on color Doppler with compression (C). No pheboliths are identified within lesion. Confirmed on pathology as a hemangioma. (Color version of figure is available online.)

Myxoma: Axial ultrasound volar wrist, radial aspect, in a 59-year-old woman presenting with a non-tender soft-tissue mass (arrow) of heterogeneous echogenicity with displacement of the radial artery over its volar surface, shown as vascular flow on power Doppler. Ultrasound imaging features are of a nonspecific soft-tissue mass.

Synovial osteochondromatosis (SO): A 39-year-old woman with primary SO of the flexor digitorum tendon sheaths extending to the DRUJ. Lat and AP DRUJ (A) with corresponding axial ultrasound image (B), demonstrating multiple ossified bodies, hyperechoic with posterior shadowing, within the tendon sheaths with synovial proliferation, hyperechoic soft tissue surrounding the tendons (arrows).

Foreign body: Sagittal wrist, volar aspect, adult male with 8 × 2 mm splinter of wood embedded in the soft tissues noted on ultrasound as a well-defined linear focus of hyperechogenicity, surrounded by a hypoechoic soft-tissue rim secondary to foreign body reaction.