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1, Hand Injuries Diagnosis by Tissue Harmonic Ultra High Resolution

1, Hand Injuries Diagnosis by Tissue Harmonic Ultra High Resolution



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Published by: mshafik2003439 on Feb 15, 2009
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Hand Injuries: Diagnosis by Tissue HarmonicUltra High-Resolution Ultrasound
Dr. Manal MS Hamed, M.D.
, and Yasser Allam, M.S.
Associate Professor of Radiodiagnosis, Ain Shams University
andOrthopedic Senior Specialist, Manshyat Al-Bakry MOH Teaching Hospital,
we hypothesize that ultrasound can accurately diagnose bone fractures andligament/tendon injuries of the dorsum of hand.
Methods and Materials:
This was a prospective study of adult patients with hand injuries.After written consent, patients were scanned with linear ultra high resolution ultrasoundwith tissue harmonic by the radiologist; subsequently standard radiographs wereperformed and read. The findings were confirmed by MRI. On ultrasound, fractured boneshad cortical interruptions and subperiosteal hematomas or displaced fragments. Injuredligament/tendon were thickened, hypoechoic or interrupted. Linear and multiple regressionanalysis were performed, p<0.05 was considered significant.
103 patients enrolled in the study 71 of which had positive findings. 26 hadfractures: 4 carpal, 5 metacarpal and 17 phalangeal. We had in all 68 ligaments/tendonsinjuries: 7 carpal interosseous ligaments, 6 thumb ulnar collateral ligaments, 8 extensorhood and 47 phalangeal collateral ligaments. Ultrasound missed 2 spiral shaft fracturesand one terminal phalangeal fracture. Cortical interruption /subperiosteal hematoma andchip displacement were significantly diagnostic ultrasound signs of fractures (p<0.005, R
 = 0.93). Ultrasound correctly diagnosed all ligament injuries (p<0.001, R
= 0.97). Thesensitivity of ultrasound in detecting fractures was 88.461%, while it sensitivity in detectingligament injuries was 100%. The overall sensitivity for detection and characterizing handinjuries was 95.77% and the specificity was 100% with no false positive results.
ultrasound of the hand is an accurate procedure that showed excellentsensitivity and specificity in diagnosis of fractures, ligaments/tendons injuries in dorsalhand injury.Abstract was accepted for oral and poster presentation in the RSSA / BSSA 2008 inGalway, Ireland.
Ultrasound has been used to evaluate bony injuries in many areas of the body
,as well as, to evaluate ligaments, tendons, and soft tissue injuries
4, 5
The advent of ultra-high-frequency sonographic transducers has significantly enhanced our ability to imagesuperficial structures. As a result, sonography now can be used to assess injuries of thetendons in the wrist and hand. Sonography provides a rapid, cheap, noninvasive, anddynamic method for examination of the soft-tissue structures of the wrist and hand
65%of scaphoid fractures are negative or equivocal on conventional radiographs obtainedimmediately after trauma; other diagnostic tools such as scintigraphy, computedtomography (CT) or MRI are employed for diagnosis to avoid unjustified immobilization,
which is inappropriate and results in both a reduction in the quality of life and an increasein health care costs
. To our knowledge, few studies have examined the role ofsonography in the analysis of the wrist and hand trauma
8, 10-12
, and none have specificallyfocused on dorsal hand trauma.
The aim of the work 
was to evaluate the accuracy of high resolution ultrasound with tissueharmonics in diagnosing fractures and ligament/tendon injuries in dorsal hand trauma.
103 adult patients enrolled in this prospective study between January 2005 and June2007. 71 (68.9%) of which had positive findings, 42 were male and 29 were females. Theirages ranged between 19 and 65 years with a mean of 37 ± 5.7SD. 32 (31.1%) didn’t havepositive findings and were excluded from the study. They were referred to the radiologydepartment from the emergency room and outpatient clinic in Jeddah Clinic Hospital Al-Kandarah, by the orthopedic physician with provisional diagnosis of a fracture followingdorsal hand injury. All patients underwent high resolution ultrasound, and the findings wereconfirmed by standard radiograph, MRI and/or surgery.
The ultrasound (US 
was performed by a high resolution linear probe 9-14MHz on aLogiq 9 (General Electric ultrasound machine), using tissue harmonic imaging. The patientwas seated on a chair opposite the radiologist, with the pronate hand placed slightly flexedon a small rolled towel to achieve passive flexion. The area of interest, pain and/orswelling, was scanned in long and short axes, and compared with the other hand. US gelwas used liberally to optimize near-field imaging, avoiding the need for a standoff pad.Focal zones were adjusted to include the level of the cortical surface of the bone. The restof the dorsal aspect of the wrist and hand were examined by defining the radial tubercle,scanning ofextensor ligaments,both rows of the carpal bones and their interosseousligaments, mainly thescapholunate ligament, extensor hood and the collateral ligaments of the fingers.
Criteria for definition 
of a
included one of the following: disruption in longitudinaland transverse planes of the echogenic thin cortical line, displacement of a fractured chipand/or the presence of a subperiosteal hematoma (fig 1).
Ligaments and tendons 
wereechogenic fibrillar structures with thin rim of synovial fluid surrounding the extensortendons. The inter-osseous ligament tear was diagnosed if the joint space was widenedand the ligament is swollen and hypoechoic (fig 2). The collateral ligament is 2-3mm thickand lies closely approximating the bone contour. Injured ligaments and Extensor tendonswere thickened and hypoechoic (fig 3). Complete rupture might reveal retracted edges witha hypoechoic area of hematoma in between (fig 4). Ultrasound images were recorded digitally on the local ultrasound machines, printed on thermal paper and stored on DVD forlatter review.
Scanning tips; 
the probe was rocked backward and forward over the tendon/ligament toavoid anisotropy artifact, which is a hypoechoic area in the tendon due to reflection of theultrasound beam when the transducer is not perpendicular to the tendon. Comparison withthe other hand was performed in all patients for standard measurements.
Criterion Standard 
The standard radiographs were read followed by MRI and/or surgery. The radiology report,MRI report and the surgical findings were reviewed as a reference standard. 
Statistical analysis 
was done by linear and multiple regression analysis, R
wascalculated and p<0.05 was considered significant.
Fig 2: Demonstrates the tornscapholunate ligament (white arrow)between the scaphoid (sc) and thelunate bonesFig 3: Demonstrates a partial tear in thecentral slip of the dorsal hood at the PIPJof the left index finger (white arrowhead).
Fig 1: (A) demonstrates a cortical defect in the middle phalanx of thering finger (arrow). (B) demonstrates cortical interruption (white arrow)with hypoechoic subperiosteal hematoma (white arrowhead) in aproximal phalanx of another patient.
Fig 4: demonstrates MPJ of the thumb with acomplete tear of the UCL. The torn edge recoils(white arrow) with a hypoechoic area seen inplace of the ligament (arrowhead).

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