EULAR on-line course on Ultrasound

Sonoanatomy
Scanning technique and
basic pathology of the
wrist and hand

David Kane, Sandrine Jousse-Joulin, Maria Antonietta D'Agostino

IN-DEPTH DISCUSSION I

Utility of ultrasound of the wrist for carpal tunnel

syndrome
 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Ultrasound (US) of the wrist is a useful technique for evaluating carpal tunnel syndrome (CTS) which is visualized
by using the palmar scan (Figure 1). Though often idiopathic, there are many secondary causes of CTS (1): flexor
tenosynovitis (Figures 2 A, B, C), carpal synovitis (Figures 3 A and B), ganglia (Figure 4), amyloid deposit, abnormal
muscles, callus, persistent median artery (Figures 5 A and B), neuroma, and fracture-dislocation of carpal bones.
Frequently CTS is an early symptom of a chronic inflammatory arthritis which is caused by median nerve
compression due to a subclinical tenosynovitis or synovitis. In cases of neuropathic symptoms in the median
nerve sensory distribution in the hand, several studies have demonstrated that US is a safe and useful technique
for visualizing the median nerve, the carpal tunnel walls and its contents (2).

In idiopathic CTS, altered flattening ratio of the median nerve, the bowing of the flexor retinaculum, swelling of
the median nerve and the nerve hyper vascularization on power Doppler have all been used as ultrasound
diagnostic criteria for CTS but nerve swelling and nerve hyper vascularization have superior diagnostic accuracy
of 91% and 95% respectively (3).

The cross-sectional area of the maximal enlargement of the median nerve, usually just proximal to carpal tunnel
(Figures 6 A and B), is the more commonly used criteria for CTS diagnostic with US, with sensitivities between
70-88% and specificities between 57-97%(2) and with cut-off values of the area between 9 and 15 mm² (2), 10
mm2 being widely used as maximum cut-off for a normal nerve area (Figures 7 A, B, C). Recent studies have
confirmed that ratio measures of the cross-sectional area maybe more accurate than a single measure of the
cross-sectional area for diagnosing the CTS (4, 5). In CTS, the US examination of the wrist, provides additional
information on the cause of CTS, and also can be used to guide a corticosteroid injection, if needed. In fact, US
of the carpal tunnel clearly depicts all the carpal tunnel structures and avoids problems related to anatomical
variants such as a bifid median nerve and a persistent median artery.

In idiopathic CTS which requires surgical intervention, US is also useful for evaluating the efficacy of the
intervention and to predict its efficacy. After CTS surgical release, US can show a regression of the median nerve
oedema and of the cross-sectional area which can correlate (6) or not (7, 8) with normalization of the
electrophysiology and symptoms of the patient.

In the latter case ultrasound can show some postoperative scar tissue encasing the median nerve or an
incomplete flexor retinaculum release (9, 10) explaining persistent symptoms of CTS after surgery.

Pre-operative ultrasound evaluation of the cross-sectional area of the nerve may predict the efficacy of surgery.
A small cross-sectional area of the median nerve can be a positive predictor (3, 6).

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Anatomy images by Sonoanatomy Group - Barcelona University 2
 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 1. Position of the probe to assess carpal tunnel syndrome. The hand is positioned with the palm up and
in a neutral position. Probe is placed transversally.

Figure 2. Flexor digitorum tenosynovitis

2 A: transversal scan of the wrist. Note the anechoic fluid around the flexor tendon.

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Anatomy images by Sonoanatomy Group - Barcelona University 3
 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

2 B: longitudinal scan of the wrist. Note the anechoic fluid around the flexor tendon.

2 C: transversal scan of the wrist. Note the aspect of the median nerve which is flattened and increased (15 mm2).

©2007-2020 EULAR
Anatomy images by Sonoanatomy Group - Barcelona University 4
 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 3. Carpal synovitis: clinical (3A) and ultrasound aspect in longitudinal dorsal scan (3B). The synovitis
shows Doppler signal and joint effusion

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 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 4. Ganglia in transverse (4A) and longitudinal (4B) palmar scan

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 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 5. Palmar transverse scan. Persistent median artery between bifid median nerve (2 arrows, figure 5A).
In the figure 5B the artery is highlighted by the Doppler (single arrow)

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 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 6. Measure of normal median nerve

6A: the measure of the cross-sectional area of the median nerve in transverse scan

6B: the measure of the thickness of the median nerve in longitudinal scan

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 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

Figure 7.
7A: Location of the median nerve under the flexor retinaculum

7B: Location of the median nerve under the flexor retinaculum

7C: Measurement of the cross-sectional area in transverse scan of the median nerve with (9 mm2 in this case)

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 Sonoanatomy Scanning technique and basic pathology of the wrist and hand– Module 2

References

1. Bianchi S, Montet X, Martinoli C, et al : High-resolution sonography of compressive neuropathies of the wrist.

J Clin Ultrasound 2004;32:451-61

2. Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the
literature. Muscle Nerve. 2003;27:26-33

3. Mallouhi A, Pülzl P, Trieb T, et al : Predictors of carpal tunnel syndrome: accuracy of gray-scale and color
Doppler sonography. AJR Am J Roentgenol 2006;186:1240-5

4. Hobson-Webb LD, Massey JM, Juel VC, et al :The ultrasonographic wrist-to-forearm median nerve area ratio
in carpal tunnel syndrome. Clin Neurophysiol 2008;119:1353-7

5. Klauser AS, Halpern EJ, De Zordo T, et al : Carpal tunnel syndrome assessment with US: value of additional
cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology.
2009;250:171-7

6. Mondelli M, Filippou G, Aretini A, et al : Ultrasonography before and after surgery in carpal tunnel syndrome
and relationship with clinical and electrophysiological findings. A new outcome predictor? Scand J Rheumatol
2008;37:219-24

7. Abicalaf CA, de Barros N, Sernik RA, et al : Ultrasound evaluation of patients with carpal tunnel syndrome
before and after endoscopic release of the transverse carpal ligament. Clin Radiol 2007;62:891-4

8. Smidt MH, Visser LH : Carpal tunnel syndrome: clinical and sonographic follow-up after surgery. Muscle Nerve
2008;38:987-91

9. Martinoli C, Bianchi S, Gandolfo N, et al : US of Nerve Entrapments in Osteofibrous Tunnels of the Upper and
Lower Limbs. RadioGraphics 2000 ; 20: S199-S217

10. Chen P, Maklad N, Redwine M, et al : Dynamic high-resolution sonography of the carpal tunnel. AJR Am J
Roentgenol 1997;168:533-7

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