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Clinical Radiology xxx (xxxx) xxx

55
Contents lists available at ScienceDirect 56
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Clinical Radiology 59
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journal homepage: www.clinicalradiologyonline.net 61
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1 66
2 67
3 68
4 69
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7 Highlights 72
8 73
9
 Most of the soft tissue thenar lesions can be characterised based on the imaging features described in this review, and 74
10 75
thus be managed in local hospitals or primary care.
11 76
12  Ultrasound is usually the first line of investigation which helps differentiate solid from cystic, and often benign from
77
13 aggressive; providing additional information through dynamic examination.
78
 MRI is needed in few cases for problem solving by narrowing the differentials and surgical planning. Q1
14 79
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53
https://doi.org/10.1016/j.crad.2019.08.025
54 0009-9260/Ó 2019 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
 YCRAD5258_proof ■ 19 September 2019 ■ 1/13

Clinical Radiology xxx (xxxx) xxx

55
Contents lists available at ScienceDirect 56
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Clinical Radiology 59
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journal homepage: www.clinicalradiologyonline.net 61
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1 66
2
3
Q6 Thenar lumps: a review of differentials 67
68
4 69
5 Q5 A. Ganguly, S.R. Chaudhary*, M. Rai, V. Kesavanarayanan, H. Aniq 70
6 71
7 Department of Radiology, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington, Cheshire
72
8 WA5 1QG, UK
73
9 74
10 75
11 art icl e i nformat ion 76
12 Most soft-tissue lumps in the hand are benign, with ganglions being the commonest, but in the
77
13 Article history: thenar region, solid soft-tissue masses are more common than a ganglion. In this review, we
78
14 Received 19 February 2019 focus on soft-tissue lesions (neoplastic and non-neoplastic) presenting as a palpable lump in 79
15 Accepted 28 August 2019 this region. A specific diagnosis can often be reached using ultrasonography and/or magnetic 80
16 resonance imaging. Most of these lesions are managed in local hospitals or primary care, 81
17 whereas some are referred to specialist centres. This review article will help both general and 82
18 musculoskeletal radiologists to diagnose and characterise these lesions, provide a guide for 83
19 further imaging, and provide an insight into imaging features that may need specific in- 84
20 vestigations such as core biopsy, tertiary referral, and further review at multidisciplinary 85
21 meetings. 86
22 Ó 2019 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. 87
23 88
24 89
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26 91
27 92
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29 94
30 Introduction pollicis, flexor pollicis brevis, and opponens pollicis. It also
95
31 includes the neurovascular structures such as common
96
32 The vast majority of lumps in the hand (approximately palmar digital nerves, the branches of the median nerve,
97
33 95%) encountered in clinical practice are benign, ganglion and ulnar nerve to thenar muscles; flexor pollicis longus 98
34 being the commonest1; however, in the thenar region, solid (FPL) tendon and tendon sheath with its synovial lining; 99
35 soft-tissue masses are way more common than ganglions, in underlying inter-carpal and first carpo-metacarpal joint 100
36 ligaments/capsule, subcutaneous fat and overlying skin. 101
our experience. Most of these are managed in primary or
37 Soft-tissue lesions in the thenar region can be cat- 102
secondary care, while some get referred to regional tumour
38 egorised based on their tissue of origin, anatomical seg- 103
39 centres.
ments, and pathology (Table 1). They form a diverse group 104
40 For the purpose of this review, we will focus on soft-
of disorders and are almost always referred for imaging. A 105
41 tissue lesions (neoplastic and non-neoplastic), which clini- 106
42 cally present as a palpable lump, in this region. The word specific diagnosis can often be reached using ultrasonog-
107
43 thenar comes from the Greek verb thenein, meaning to raphy (US) and magnetic resonance imaging (MRI) or a
108
44 strike. The thenar eminence, commonly known as the ball combination of both, although often plain radiographs can 109
45 of the palm, comprises of a group of muscles at the base of also provide additional information. 110
46 the thumb namely abductor pollicis brevis, adductor This review article will help both general and musculo- 111
47 skeletal radiologists to diagnose and characterise these le- 112
48 sions, provide a guide for further imaging and give an 113
49 * Guarantor and correspondent: S. R. Chaudhary, Department of Radi- 114
insight into imaging features that may need specific in-
50 ology, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Lane,
vestigations such as core biopsy, tertiary referral, and 115
51 Warrington, Cheshire WA5 1QG, UK. Tel.: þ44 1925 662731.
further review at multidisciplinary meetings. 116
52 E-mail address: snehansh.chaudhary@nhs.net (S.R. Chaudhary).
117
53 118
https://doi.org/10.1016/j.crad.2019.08.025
54 0009-9260/Ó 2019 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. 119

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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2 A. Ganguly et al. / Clinical Radiology xxx (xxxx) xxx

1 Table 1 Neoplastic 66
2 Classification of thenar lesions. 67
3 Neoplastic
68
4
Benign tumours 69
Tumours (subclassified by tissue types)
5 Benign: lipoma, schwannoma, GCT 70
6 Malignant: sarcoma Lipoma 71
7 Vascular malformation (KlippeleTrenaunay, Maffucci syndrome, true Lipomas (Fig 1) are the most commonly occurring soft- 72
8 haemangioma) tissue tumour in the whole body and can develop in any 73
9 Non-neoplastic 74
fat-containing compartment. They can be superficial or
10 Degenerative 75
Ganglion/synovial cysts deep; the former being more common and can be found in
11 76
Tenosynovitis/tendinopathy subcutaneous, interfascial, subfascial, or intramuscular
12 77
Traumatic (history of trauma/chronic repetitive injury) planes. They are hyperechoic encapsulated compressible
13 Haematoma 78
14
masses separate from the surrounding fat containing linear 79
Foreign body granuloma
15 Implantation cyst/epidermoid
internal echoes on ultrasound. In our experience, intra- 80
16 Tenosynovitis/tendinopathy muscular lipomas are often infiltrating and can be confused 81
17 Infection with muscle tear/scarring. Characteristic MRI features 82
18 Abscess include a well-defined lesion that is T1 and T2 hyperintense 83
19 Inflammatory 84
with homogeneous signal loss on fat-suppressed (FS) se-
Granuloma
20 quences. It is recognised that some lipomas can show 85
Rheumatoid nodule
21 contrast enhancement, more so if there is a fibrovascular 86
Tophi
22 87
Foreign body granuloma stromal structure.2e4
23 88
24 89
25 90
26 91
27 92
28 93
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30 95
31 96
32 97
33 98
34 99
35 100
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37 102
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Figure 1 Lipoma. (a) Coronal proton-density-weighted (PDW) mDixon turbo spin echo (TSE; 30 ms echo time [TE], 3,000 ms repetition time
60 125
[TR]) and (b) T1-weighted TSE (20 ms TE, 520 ms TR) of the left hand showing a well-defined oval lesion (asterisk) in the thenar region with high
61 126
signal on T1-weighted image and uniform signal loss on PDW FS imaging in keeping with a benign lipoma. (c) Sagittal ultrasound image of the
62 127
same patient showing a uniform hyper-echogenic well-defined mass superficial to the FPL tendon (arrow), consistent with a lipoma.
63 128
64 129
65 130

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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Figure 2 GCT of the tendon sheath. (a) Coronal T1-weighted TSE (20 ms TE, 520 ms TR) and (b) PDW mDixon TSE (30 ms TE, 3,000 ms TR) of the
20 85
right hand showing a well-defined oval mass in the thenar region (asterisk), inseparable from the FPL tendon (arrow), with uniform inter-
21 86
mediate to low signal on T1-weighted image and mixed signal on T2-weighted image; areas of low T2 signal corresponding to haemosiderin
22 87
deposit. Histology at excision revealed GCT of tendon sheath.
23 88
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60 Figure 3 Fibroma of the tendon sheath. (a) Sagittal T2-weighted mDixon TSE (100 ms TE, 1,574 ms TR) and (b) and T1-weighted TSE (20 ms TE, 125
61 520 ms TR) images of the left hand, showing a well-defined lesion (arrow), with heterogeneous high signal on T2-weighted images and low to 126
62 intermediate signal on T1-weighted images, inseparable from the FPL tendon (curved arrow). There was heterogeneous enhancement on fat 127
63 suppressed post contrast images (not included). There was no “blooming” on GRE sequence. (c) Sagittal ultrasound image of the thenar region of 128
64 the same patient shows a well-defined hypoechoic, solid lesion (asterisk) closely related to the FPL tendon (arrow). Histology at excision revealed 129
65 tendon sheath fibroma. 130

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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4 A. Ganguly et al. / Clinical Radiology xxx (xxxx) xxx

1 Incomplete fat suppression, internal septa, and contrast mass in schwannoma but central or obliterated by the mass 66
2 enhancement are more likely to be seen in atypical lipomas in neurofibromas.12 67
3 or liposarcomas and should be reviewed and followed up Lipofibromatous hamartoma are rare benign peripheral 68
4 69
carefully. Lipomas without atypical features have an nerve sheath tumours, which can affect the median nerve
5 70
extremely low rate of malignant transformation and are (Fig 5), but are more likely to present as lumps in the wrist
6 71
7 often surgically excised for cosmetic reasons3. rather than in the true thenar region.13 72
8 73
9 Giant cell tumour of the tendon (GCT) sheath 74
10 GCTs of the tendon sheath (Fig 2) are the second com- 75
11 monest soft-tissue tumour of the hand, after ganglions. 76
12 They are benign tumours mostly affecting middle-aged 77
13 adults and have a good prognosis but often recur post- 78
14 excision.5,6 GCTs can be diffuse or localised; the latter being 79
15 more common in the hand. The presence of haemosiderin 80
16 81
with low T2 signal, secondary to reduction of T2-relaxation
17 82
18
time, is considered highly suggestive of GCT of tendon 83
19 sheath, albeit such low T2 signal is more commonly 84
20 described in the diffuse types.7 Both MRI and ultrasound 85
21 show them as well-defined masses, eccentrically located in 86
22 association with a tendon.7 They are typically hypoechoic 87
23 on ultrasound and hypervascular on Doppler. The lesion 88
24 appears closely related to a tendon but does not interfere 89
25 with the movement of the underlying tendon (as they arise 90
26 91
from the tendon sheath). They are of low T1 and interme-
27 92
diate to high T2 signal. Most lesions show heterogeneous
28 93
29
contrast enhancement. Susceptibility artefacts due to hae- 94
30 mosiderin are a helpful discriminating feature from other 95
31 differentials such as focal nodular synovitis.7,8 In the thenar 96
32 region they are typically related to the FPL tendon. 97
33 98
34 Tendon sheath fibroma 99
35 Tendon sheath fibromas (Fig 3) present as slowly 100
36 growing lesions. They are commoner in men, with upper 101
37 extremity particularly fingers and hands, being the com- 102
38 103
monest site. On MRI, they are inseparable from the tendon
39 104
sheath showing low T1 and T2 signal, attributed to high
40 105
41 collagen content of the tumour. More cellular lesions with 106
42 myxoid matrix show high T2 signal. Variable contrast 107
43 enhancement has been reported, from none to moderate. 108
44 Differential includes GCT of the tendon sheath, which 109
45 shows “blooming artefact” on gradient echo (GRE) images 110
46 because of their haemosiderin content (a feature not seen in 111
47 tendon sheath fibroma).9 112
48 113
49 114
Peripheral nerve sheath tumours
50 115
Peripheral nerve sheath tumours are uncommon and
51 116
52 consist of schwannomas (Fig 4) and neurofibromas (often 117
53 difficult to distinguish), affecting branches of the median 118
54 nerve, muscular, or common palmar digital divisions. On 119
55 MRI, both are of high T2 signal, low to intermediate T1 120
56 signal and demonstrating homogeneous contrast 121
57 enhancement. MRI may demonstrate a “split-fat sign” with 122
58 a thin rind of fat surrounding the lesions and triangular Figure 4 Schwannoma. (a) Axial T1-weighted TSE (18 ms TE, 500 ms 123
59 polar fat pads. TR) and (b) PDW FS (30 ms TE, 3,000 ms TR) MRI images of the left 124
60 hand showing a well-defined oval lesion (asterisk) in the thenar re- 125
Schwannoma are well defined, hypoechoic, and solid in
61 gion with low signal on T1-weighted image and high signal on PD FS 126
appearance, often showing internal vascularity on Doppler
62 image. (c) Sagittal ultrasound image of the thenar region of the same 127
63 and continuity with a peripheral nerve (rat-tail sign); some patient showed a well-defined oval solid hypoechoic lesion (asterisk) 128
64 show cystic change and posterior acoustic enhance- with split-fat sign and polar caps of fat (x) in keeping with a 129
65 ment.10,11 Typically, the parent nerve is eccentric to the schwannoma. 130

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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1 undifferentiated pleomorphic sarcoma.15 This tumour af- 66

2 fects a wide age group (15e80 years) and has a slight male 67
3 predominance. It has a predilection for the retroperitoneum 68
4 69
and lower extremities, and occurrences in the hand are
5 70
rare.16 Ultrasonography is a useful first-line investigation to
6 71
7 distinguish solid and cystic masses; most sarcomas pre- 72
8 senting as a solid hypoechogenic to mixed echogenic le- 73
9 sions with variable vascularity. MRI is the technique of 74
10 choice for tumour characterisation and accurate local 75
11 staging. Typical features include a pseudocapsule (com- 76
12 pressed tissue surrounding the mass), low T1 signal and 77
13 heterogeneously high T2 signal with enhancement on 78
14 contrast-enhanced studies. 79
15 80
It is important to note that soft-tissue sarcomas often are
16 81
non-specific in appearance on ultrasound at an early stage.
17 82
18 It may appear well-defined and avascular, mimicking a 83
19 benign pathology. Often, duration of lump, rate of change in 84
20 size or symptoms can prove useful. If there are any suspi- 85
21 cious features, such as lobulate margins, mixed echoge- 86
22 nicity, calcification, vascularity, or surrounding soft-tissue 87
23 changes on ultrasound, they should be followed up with 88
24 contrast-enhanced MRI and reviewed at regional sarcoma 89
25 centre multidisciplinary meetings regarding biopsy, which 90
26 91
is often best performed in regional tumour centres. All
27 92
indeterminate lesions require imaging and clinical follow-
28 93
29 up to ensure benignity of the lesion. 94
30 95
31 Vascular pathologies 96
32 97
33 Vascular anomalies 98
34 Vascular anomalies are classified into vascular tumours 99
35 and vascular malformations.17 The vascular tumours are 100
36 101
further subdivided into benign, locally aggressive, and
37 102
malignant. Soft-tissue haemangiomas are the commonest
38 103
39
type of benign vascular tumours and are the fourth com- 104
40 monest hand tumour.18 The vascular malformations on the 105
41 other hand are also further subdivided into simple, com- 106
42 bined, those that are anomalies of major named individual 107
43 vessels, those that are associated with other syndromes, 108
44 and otherwise unclassified anomalies. 109
45 The simple vascular malformations are characterised as 110
46 venous, capillary, lymphatic, arterial, arteriovenous mal- 111
47 112
formations, or fistula based on the predominant vascular
48 113
channel involved.19 They can be divided into low-flow
49 114
50
(venous, capillary, lymphatic) and high-flow types (arter- 115
51 Figure 5 Fibrolipomatous hamartoma. (a) Coronal T1-weighted TSE ialised arteriovenous malformation/arteriovenous fistula). 116
52 (18 ms TE, 500 ms TR), (b) axial T1-weighted TSE (18 ms TE, 500 ms Low-flow types are septate lesions with low to intermediate 117
53 TR), and (c) axial PDW FS (30 ms TE, 3,000 ms TR) MRI images of the T1 signal and high T2/short tau inversion recovery (STIR) 118
54 right hand, showing a predominantly high T1 (fat) signal lobulate signal; FS T2-weighted/STIR images being by far the best at 119
55 lesion (arrows) extending along digital branches of the median nerve, 120
depicting them. High-flow lesions show serpiginous
56 with low signal on PDW FS image, consistent with a fibrolipomatous 121
feeding arteries and draining veins with flow voids on spin
57 hamartoma. 122
echo images19 (Fig 6). Phleboliths are more common in
58 123
cavernous/mixed types and appear as areas of low T2 signal
59 124
and blooming artefact on GRE sequences. On ultrasound,
60 125
Malignant tumours they appear solid, lobulate, hypoechoic to heterogeneous in
61 126
62 echogenicity with weak or no flow on Doppler. 127
63 Sarcoma Some types of vascular malformations could be associ- 128
64 These rare tumours can affect any age, gender, or ated with systematic dysplasia, such as Maffucci syndrome 129
65 anatomical site.14 The most common histological subtype is (soft-tissue haemangiomas and enchondromas), 130

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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1 naunayeWeber syndrome (soft-tissue hae-

KlippeleTre change has also been implicated. These cysts usually affect 66
2 mangiomas, venous varicosities, and soft-tissue hypertro- adults but can be seen in children.22 Although they mostly 67
3 phy), ParkeeWeber syndrome (soft-tissue haemangioma, arise on the dorsal aspect of the wrist, finger pulleys are the 68
4 69
arteriovenous malformation, and soft-tissue hypertrophy), second commonest site after the wrist.23,24 In the thenar
5 70
Bean’s syndrome (soft-tissue and bowel haemangiomas) region, these are often related to the radioscaphoid, sca-
6 71
7 and KasabacheMerritt syndrome (soft-tissue haemangio- pholunate, or scaphotrapeziotrapezoidal (STT) joints. 72
8 mas, haemangioendothelioma, and thrombocytopenia).20 Unruptured ganglions are well-defined, non-compressible, 73
9 mostly anechoic structures with posterior acoustic 74
10 Aneurysm and pseudoaneurysm enhancement on ultrasound, with occasional peripheral 75
11 True aneurysms affecting superficial or deep palmar vascular flow on Doppler examination. Sometimes, internal 76
12 branches of the radial artery are rare. Post-traumatic echogenicity and septa are also seen. On MRI, a typical 77
13 pseudoaneurysms occur following penetrating injuries. ganglion has low T1 and high T2 signal. To aid surgical 78
14 Rarely, thenar hammer syndrome present as lumps in the planning, the exact extent of the cyst and its relationship to 79
15 thenar region. Thenar hammer syndrome is a rare entity 80
the joint may need to be delineated by contrast-enhanced
16 81
resulting in damage to the distal radial artery from chronic MRI. Subtle rim enhancement can be seen on post-
17 82
18
repetitive trauma.21 On ultrasound, they can show tortu- contrast MRI.25,26 83
19 osity, intimal thickening, or stenosis of a distal radial artery 84
20 branch. Mixed appearances may be seen on Doppler ultra- Tenosynovitis and tendinopathy 85
21 sound and MRI, depending on the degree of thrombus and Tenosynovitis (Fig 10) refers to inflammation of the 86
22 flow; however, angiography is still considered to be the tendon sheath, either secondary to chronic repetitive 87
23 reference standard imaging technique to make a diag- injury/abnormal use or inflammatory joint disease. It ap- 88
24 nosis,21 which may further demonstrate small aneurysms pears as fluid surrounding the tendon, within the tendon 89
25 or a corkscrew appearance of the vessel (Fig 7). sheath, affecting the FPL tendon in the thenar region. Ten- 90
26 91
dinosis/tendinopathy refers to thickening of the tendon
27 92
Degenerative with hypoechogenicity and loss of fibrillar pattern on ul-
28 93
29
trasound. On MRI, tendinosis appears as intermediate T1 94
30 Ganglion and synovial cysts and T2 signal, with higher T2 signal more suggestive of a 95
31 Ganglia and synovial cysts (Figs 8 and 9) are the com- tear.27 Tenosynovitis appears as low T1 and high T2 signal 96
32 monest palpable lesions of the hand, but not the thenar surrounding the tendon. It is suggested that tenosynovitis 97
33 eminence, where soft-tissue tumours are by far the com- of flexor tendons of the hand are more likely to represent 98
34 rheumatoid arthritis than other inflammatory joint dis- 99
monest focal masses in our practice. Ganglions are mainly
35
associated with ligamentous injury though degenerative ease.28 Often there is associated prominent thickening of 100
36 101
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62 Figure 6 Vascular malformation. (a) Axial T1-weighted TSE (18 ms TE, 500 ms TR), and (b) contrast-enhanced computed tomography (CT) 127
63 images showing a clump of abnormal blood vessels (arrow) corresponding to a palpable lump in the thenar region, consistent with a benign 128
64 vascular malformation. (c) Coronal digital subtraction angiogram image of the same patient shows the vascular malformation in the thenar 129
65 region (arrow). The patient was known to have KlippeleTre naunay syndrome and multifocal vascular malformations. 130

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40 Figure 7 Thenar hammer syndrome. (a) Sagittal ultrasound of a palpable lump in the thenar region of the right hand shows a thick-walled 105
41 stenotic segment of distal radial artery (asterisk). (b,c) Coronal digital subtraction angiogram images of the same patient shows corkscrew 106
42 configuration (arrow) of distal radial artery segment and a focal aneurysm (curved arrow) in keeping with thenar hammer syndrome. (Inci- 107
43 dentally distal ulnar artery is occluded secondary to previously diagnosed hypothenar hammer syndrome.) 108
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61 Figure 8 Ganglion and epidermoid cyst. (a) Coronal T1-weighted FS contrast-enhanced (20 ms TE, 636 ms TR), and (b) T2-weighted TSE (120 ms TE, 126
62 3,000 ms TR) MRI images, showing a well-defined oval lesion (asterisk) with high signal on T2-weighted image, thin rim and septal enhancement on 127
63 enhanced T1-weighted FS image (asterisk), corresponding to a palpable lump in the thenar eminence, which would fit with a ganglion. 128
64 129
65 130

Please cite this article as: Ganguly A et al., Thenar lumps: a review of differentials, Clinical Radiology, https://doi.org/10.1016/j.crad.2019.08.025
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8 A. Ganguly et al. / Clinical Radiology xxx (xxxx) xxx

1 the A1 or A2 pulley (or an intrinsic ganglion), which can be intermediate T1 and high to mixed T2 signal, with periph- 66
2 felt as a lump. In contrast to GCTs, thickening of the pulleys eral low signal fibrous capsule showing enhancement post- 67
3 does impede tendon excursion during dynamic examina- contrast.35 68
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tion (Fig 11).
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Pulleys are thickened regions in flexor tendons sheaths
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7 of the digits. Pulleys in the thumb differ from the digital 72
8 pulleys. Four morphometric patterns are described con- 73
9 sisting of A1 pulley (at the MCPJ), oblique pulley (at prox- 74
10 imal half of proximal phalanx), A2 pulley (distal half of 75
11 proximal phalanx) and a variable pulley (Av) between the 76
12 A1 and oblique pulleys. Oblique pulley is considered to be 77
13 most important preventing bowstringing of FPL, while A1 78
14 pulley is most commonly implicated in trigger thumb.29 79
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Full-thickness tears of the FPL tendon, although un-
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common, can also present as a lump in the thenar region.
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18 Ultrasound will demonstrate the torn tendon ends and fluid 83
19 within an empty tendon sheath. 84
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21 Traumatic 86
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Haematoma 89
25 Ecchymosis of the palm should raise the suspicion of a 90
26 haematoma (Fig 12), in association with history of soft- 91
27 tissue injury when evaluating a complex thenar mass on 92
28 imaging. Haematomas consist of blood products at different 93
29 ages, and therefore, have a protean appearance on imaging. 94
30 Acute haematomas can appear both hypo- and hyperechoic 95
31 and over time, become more heterogeneously hypoechoic 96
32 97
or anechoic and eventually resolve.30 MRI is better able to
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age haematomas. Acute (<7 days) haematomas are typically
34 99
35 iso- or hypointense to muscle on T1-and T2-weighted MRI 100
36 images. Subacute (1 weeke3 months) haematomas are 101
37 usually hyperintense on T1 and T2-weighted images. 102
38 Chronic haematomas can have a prominent hypointense 103
39 rim representing a wall of collagenous fibrous tissues and/ 104
40 or haemosiderin.31 Peripheral enhancement is demon- 105
41 strated on contrast-enhanced images, while ultrasound 106
42 shows a complex cystic/missed echogenic mass with pe- 107
43 108
ripheral vascularity on Doppler ultrasound.
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46
Foreign body granuloma 111
47 Retained foreign body in the soft tissues can cause an 112
48 inflammatory reaction causing formation of fibrous tissue 113
49 and granuloma.32 There can be a delay in diagnosis when 114
50 the patient forgets the (often minor) injury that caused the 115
51 skin penetration. What adds to the diagnostic conundrum is 116
52 the fact that not all foreign bodies associated with the 117
53 granuloma are radiopaque.33 Ultrasound is the technique of 118
54 119
choice as it capitalises on the wide differences in the
55 120
acoustic impedance of both radiopaque and radiolucent
56 121
foreign bodies, such as wood and glass. These are easily
57 Figure 9 Synovial cyst with loose bodies. (a) Axial PD-weighted FS 122
58 recognised as echogenic areas with marked posterior (30 ms TE, 3,000 ms TR), and (b) T1-weighted TSE (18 ms TE, 500 ms 123
59 acoustic shadowing.34 On MRI, the foreign body returns low TR) MRI images of the right hand, showing a well-defined low T1 and 124
60 T1 and T2 signal, appearing as a signal void. The sur- high PDW FS lesion (curved arrow) with low and high T1 signal loose 125
61 rounding soft-tissue change depends on the age of the bodies (straight arrows) on the volar aspect of the first carpometa- 126
62 foreign body; in acute presentation inflammatory change is carpal joint, consistent with a synovial cyst. (c) Dorso-palmar view 127
63 seen as low on T1-weighted and high on T2-weighted fluid (DP) radiograph showing osteoarthrosis of the first carpometacarpal 128
64 sensitive sequences. Chronic granuloma appears as low to joint and associated loose bodies (arrow). 129
65 130

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19 Figure 10 Tenosynovitis. (a) Sagittal and (b) axial T2-weighted mDixon TSE (100 ms TE, 1,574 ms TR) MRI images of the right hand showing 84
20 loculated fluid (asterisk) in the FPL tendon (arrow) sheath consistent with stenosing tenosynovitis. 85
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61 Figure 11 A1 pulley thickening. (a) Axial ultrasound image of the left thenar eminence showing a well-defined non-vascular eccentric hypo- 126
62 echoic thickening of the A1 pulley (asterisk) in a patient with known rheumatoid arthritis, corresponding to a palpable lump; FPL tendon (F) 127
63 appears mildly thickened with sluggish glide on dynamic scan (not shown) in keeping with mild tendinosis. Schematic long axis (b) and axial (c) 128
64 images of the finger illustrating the anatomy of the pulley system of the flexor tendons. M, Metacarpal; F, Flexor tendon; A1, A1 pulley; Av, 129
65 Variable pulley; Ob, Oblique pulley; A2, A2 pulley; P, Proximal phalanx; D, Distal phalanx; S, tendon sheath. 130

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59 Figure 12 Haematoma. (a) Coronal T2-weighted mDixon TSE (100 ms TE, 1,574 ms TR) and (b) axial T1-weighted TSE (20 ms TE, 520 ms TR) MRI 124
60 images of the same patient showing high T2 and high T1 signal centrally, corresponding to the haematoma (asterisk), with surrounding 125
61 abnormal vascular channels (arrow). (c) Axial ultrasound image of a lump on the thenar region of the left hand showing a well-defined avascular 126
62 hypoechoic lesion with slow “swirling” of echogenic debris, in keeping with a post-traumatic haematoma. Surrounding abnormal vascular 127
63 channels are noted with low resistance biphasic flow in a patient with known KlippeleTre naunayeWeber syndrome. 128
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38 Figure 13 Abscess. (a) T1-weighted post-contrast FS (20 ms TE, 636 ms TR) MRI image and (b,c) axial ultrasound images of the left thenar region 103
39 shows abnormal thick irregular rim enhancement with central low signal on MRI (asterisk). Corresponding ultrasound image shows a well- 104
40 defined avascular hypoechoic mass with mild peripheral hypervascularity (asterisk) consistent with an abscess, closely related to an other- 105
41 wise unremarkable FPL tendon (arrow) in a patient with history of previous penetrating injury. 106
42 107
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44 Epidermoid inclusion cyst mass, but also can guide aspiration for diagnosis and/or 109
45 Epidermoid inclusion cysts occur when the epidermal treatment. Tenosynovitis, periostitis, or features indicative 110
46 elements implant into the dermal layer as a consequence of osteomyelitis may be seen on imaging. Often, there is a 111
47 of previous skin penetration, trauma, or surgery.36 Typical history of previous penetrating injury. A hypoechoic mass 112
48 113
features include a painless, slowly enlarging superficial with through transmission is described in simple abscesses,
49 114
lump, similar to ganglion, and other benign soft-tissue whereas more complex collections show mixed echoge-
50 115
51 tumours. They are most commonly reported in the fin- nicity with a thick hyperechoic hypervascular rim. A 116
52 gertips, but the thenar region can also be affected. phlegmon is as a solid inflammatory mass with poorly 117
53 Unruptured epidermoid cysts appear as well-defined defined margins, mixed echogenicity, and increased 118
54 lesion with high T2 signal, with low signal internal vascularity. On MRI, the abscess would show low to inter- 119
55 debris often described. Contrast-enhancced images show mediate T1 and high T2 signal with an enhancing capsule of 120
56 thin rim enhancement. variable thickness. Enhancing walls, septa, and associated 121
57 sinus tracts are best demonstrated on FS contrast-enhanced 122
58 Infection T1-weighted images.35 123
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Abscess Inflammatory
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62 Soft-tissue infection with abscess (Fig 13) formation may 127
63 present as a soft-tissue mass and imaging has a role in both Rheumatoid nodule 128
64 the diagnosis and management of these conditions.1 Ul- These are associated with long-standing rheumatoid 129
65 trasonography not only helps to define the extent of the arthritis, and affect 20e30% of rheumatoid arthritis (RA) 130

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