Acute suppurative tenosynovitis of the hand: diagnosis with US

Imaging of MSK infections in the ER

Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.

First Metatarsophalangeal Joint Pain in Athletes: Diagnosis, Management, and Return to Play Considerations

ABSTRACT

The first metatarsal-phalangeal joint plays a key role for athletes of various disciplines. When an athlete presents for evaluation of pain at this joint, there are several causes that should be considered. The purpose of this article is to review common injuries including turf toe, sand toe, extensor and flexor hallucis longus tendinopathy, sesamoiditis, and metatarsalgia and provide current evidence-based recommendations for diagnosis, management, and return to play considerations. Conditions not specific to athletes like gout and hallux rigidus also are discussed. Mechanism of injury, physical examination, and imaging such as weight-bearing radiographs and point-of-care ultrasound can help with diagnosis. Treatment of many of these injuries begins with nonsurgical management strategies including footwear or activity modification, physical therapy, and select interventions.

Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review

Musculoskeletal soft-tissue infections include a wide range of clinical conditions that are commonly encountered in both emergency departments and non-emergency clinical settings. Since clinical signs, symptoms, and even laboratory tests can be unremarkable or non-specific, imaging plays a key role in many cases. MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections. Ultrasound is a fundamental tool, especially for the evaluation of superficially located diseases and for US-guided interventional procedures, such as biopsy, needle-aspiration, and drainage. Conventional radiographs can be very helpful, especially for the detection of foreign bodies and in cases of infections with delayed diagnosis displaying bone involvement. This review article aims to provide a comprehensive overview of the radiological tools available and the imaging features of the most common musculoskeletal soft-tissue infections, including cellulitis, necrotizing and non-necrotizing fasciitis, foreign bodies, abscess, pyomyositis, infectious tenosynovitis, and bursitis.

Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema

Introduction: Pyogenic flexor tenosynovitis is an unusual complication of dyshidrotic eczema. The diagnosis has traditionally been made by Kanavel’s signs. Point-of-care ultrasound can be a useful adjunct in the diagnosis of this surgical emergency. Case Report: We report the case of a 23-year-old male who presented with right middle finger pain and swelling and an overlying eczematous rash. The use of point-of-care ultrasound was performed to aid in the diagnosis of pyogenic flexor tenosynovitis. An incision and drainage was performed with deep wound cultures positive for Staphylococcus aureus. Discussion: The presentation of pyogenic flexor tenosynovitis with underlying concomitant dermatological disease can complicate this challenging diagnosis. Point-of-care ultrasound can be an effective adjunct in revealing pyogenic flexor tenosynovitis rather than relying solely on the classical Kanavel’s signs, leading to earlier treatment. Conclusion: Our case demonstrates that point-of-care ultrasound can be a rapid and effective tool for the diagnosis of pyogenic flexor tenosynovitis in the setting of superimposed dermatological diseases.

Imaging musculoskeletal soft tissue infections

Musculoskeletal soft tissue infections are not uncommonly encountered in both the clinic and Emergency Department setting. The clinical diagnosis is not always evident as these infections can have variable presentations depending on the duration and depth of disease extension through the soft-tissue layers. Imaging often plays an important role in diagnosing the infection, defining the extent of involvement, directing tissue sampling, and in monitoring treatment response. After initial radiographs, ultrasound (US) is often the next modality utilized to evaluate patients with suspected soft tissue infections given its low cost, availability, portability, and potential for real-time guidance of fluid aspiration. The widespread use of cross-sectional imaging with magnetic resonance imaging (MRI) and computed tomography (CT) has greatly increased the radiological diagnosis in conditions where US may be limited. In addition, CT and MRI allow a thorough evaluation of disease extension, including assessment of joint spaces, tendons, and osseous changes indicative of bone involvement. This review will focus on the radiological findings of soft tissue infections on US, CT, and MRI.

Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department

Introduction

Pyogenic flexor tenosynovitis (PFT) is difficult to diagnose on clinical grounds alone as many patients requiring an operation do not have all four of Kanavel’s signs. Previous studies have shown that hypoechoic fluid surrounding the flexor tendon on ultrasound is associated with this diagnosis. We sought to determine if emergency physicians (EPs) could recognize this finding in patients with suspected flexor tenosynovitis using point-of-care ultrasound (POCUS).

Methods

We present a retrospective case series of seven patients suspected of PFT who had hypoechoic fluid surrounding the tendon on POCUS performed by the treating EP. We report on the patient characteristics, history of trauma by puncture wound, number of Kanavel’s signs, treatment course, and operative findings.

Results

We identified seven patients suspected to have flexor tenosynovitis by the emergency department attending physician who had anechoic or hypoechoic fluid surrounding the flexor tendon on real-time POCUS examination. Patients ranged in age from 16 – 51 years. All were male. All patients had at least two of Kanavel’s signs on examination. Five of seven (71%) patients had history of recent trauma to the affected hand. Four of seven (57%) were managed in the operating room. One of seven (14%) had incision and drainage at the bedside, and the remaining two (28%) were managed non-operatively and successfully with antibiotics alone.

Conclusion

Our study demonstrates that EPs can recognize the finding of hypoechoic or anechoic fluid surrounding the flexor tendon on POCUS.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound

BACKGROUND

Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis.

CASE REPORT

A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 10³/μL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Usefulness of ultrasound for the diagnosis of pyogenic flexor tenosynovitis: A prospective single-center study of 57 cases

Pyogenic flexor tenosynovitis (PFT) is a functional emergency in hand surgery; however, its diagnosis can be difficult to make. It should always be considered when a patient presents with an inflamed finger. The goal of this study was to investigate the usefulness of ultrasound in the diagnosis of early PFT. Seventy-three patients with suspected pyogenic flexor tenosynovitis were candidates for the study. Since the diagnosis of PFT was obvious in 16 patients, they were excluded from the study and immediately underwent surgery. The remaining 57 patients underwent a clinical examination by a senior surgeon, a blood test for C-reactive protein levels and an ultrasound (US). The US results were compared to the intraoperative findings if the patients were operated or to the clinical outcome in non-operated patients. Seventeen patients had the US diagnosis of PFT confirmed intraoperatively. In 10 patients, the US diagnosis of PFT was not confirmed intraoperatively. In 29 other patients, the diagnosis of PFT was ruled out by US; they all had good outcomes after being treated with antibiotics. In one patient for whom the diagnosis of PFT had been ruled out by US, PFT was actually present. Ultrasound had 94% sensitivity, 65% specificity, 63% positive predictive value, and 95% negative predictive value. Ultrasound is useful as a diagnostic tool for managing early PFT thanks to its excellent negative predictive value and specificity. This objective examination complements the surgeon's subjective clinical examination.

Point-of-Care Ultrasound in the Evaluation of Pyogenic Flexor Tenosynovitis

A 4-year-old girl presented to the emergency department for evaluation of finger swelling after a dog bite. Point-of-care ultrasound was used to diagnose pyogenic flexor tenosynovitis of the digit after visualizing a fluid collection within the flexor tendon sheath. The patient underwent emergent incision and drainage of the digit with good outcome.

Magnetic resonance imaging in the visualization of benign tumors and tumor-like lesions of hand and wrist

The differential diagnosis of benign tumors and tumor-like lesions of the hand and wrist region is important with regard to choosing the therapy (medical versus surgical), or to decide to just follow-up the lesion. In most of the cases the proper analysis of MRI findings in correlation with the patient's history is sufficient to meet a specific diagnosis. However, diagnostic confusion is not uncommon as there are numerous lesions affecting the hand and wrist region. This pictorial essay offers a practical radiological approach to benign tumors and tumor-like lesions of the hand and wrist region based on most frequently observed MRI findings.

Ultrasound of the digital flexor system: Normal and pathological findings()

Recent improvements in ultrasound (US) software and hardware have markedly increased the role of this imaging modality in the evaluation of the musculoskeletal system. US is currently one of the main imaging tools used to diagnose and assess most tendon, muscle, and ligament disorders. Compared with magnetic resonance imaging, US is much less expensive; it has no contraindications and is also widely available. Diseases affecting the digital flexor system (DFS) require early diagnosis if treatment is expected to limit functional impairment of the hand. US scans performed with high-resolution, broad-band transducers allows superb visualization of the flexor tendons of the hand and the annular digital pulleys. In addition, dynamic US can be used to assess movement of the tendon within the pulleys during passive or active joint movements. This article examines the anatomy and US appearance of the normal DFS and reviews the US findings associated with the most common disorders affecting it.

Ultrasound imaging of non-traumatic lesions of wrist and hand tendons

Non-traumatic tendon lesions are common and diverse at the wrist and hand. Improvements in high-resolution ultrasound (US) are producing increasingly high-quality images of superficial structures, thus expanding the indications for this imaging modality as a tool for investigating musculoskeletal disorders. The objective of this work is to provide an update on the uses and performance of US in non-traumatic tendon disorders of the wrist and hand. The relevant anatomy is reviewed, and the normal and abnormal ultrasound scan features are described in detail, with attention not only to the tendons but also to closely related structures such as synovial sheaths and bands. The contribution of US to the evaluation of each of the most common disorders is discussed.

Musculoskeletal gene therapy and its potential use in the treatment of complicated musculoskeletal infection

Tissue repair is a major issue in orthopedics. Many musculoskeletal tissues, including cartilage, meniscus, and the anterior cruciate ligament, heal poorly after injury. Recent studies have led to the identification of numerous growth factors and other gene products that can promote the regeneration of damaged musculoskeletal tissues. In the last century, the discovery and evolving use of antibiotics has significantly decreased the prevalence and severity of infectious diseases. In many orthopedic scenarios, however, treatment of infections can be difficult, and often involves a prolonged course of antibiotics with concomitant surgical interventions and loss of tissue. Although studies have demonstrated the successful transfer of target genes and the associated manipulation of the musculoskeletal tissue environment, researchers have made few attempts designed to use gene therapy to treat infectious musculoskeletal diseases in animal models. Before it is possible to use gene-based approaches to treat such diseases effectively, researchers must perform more studies to investigate the potential problems that may arise when using gene therapy in an infectious environment.

Pediatric upper extremity injuries

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems.

Pasteurella multocida tenosynovitis of the hand: sonographic findings

Pasteurella multocida is a common cause of infection in humans subsequent to bites or scratches by dogs and, particularly, cats. This infection usually results in superficial skin and soft tissue infections. Sonography can be used for diagnosing inflammatory conditions affecting tendons, including acute and chronic tenosynovitis. P. multocida tenosynovitis is rare, and the diagnosis can be missed if adequate tests are not performed. We report 2 cases of P. multocida tenosynovitis of the hand and wrist in which sonography played a valuable role in assessing the affected tissues and guiding fine-needle aspiration of fluid accumulations in the involved tendon sheaths. The diagnosis was confirmed microbiologically in each case.

Finger pulley injuries in extreme rock climbers: depiction with dynamic US

PURPOSE

To determine the ability of dynamic ultrasonography (US) to depict finger pulley injuries in extreme rock climbers.

MATERIALS AND METHODS

Sixty-four extreme rock climbers (climbing levels 8-11 on a scale ranging from 1 to 11; Union Internationale des Associations d'Alpinisme) with finger injuries (75 symptomatic and 181 asymptomatic fingers) were examined by using US, with the transducer operating at 12 MHz. The distance between the flexor tendon and phalanx was evaluated in extension and forced flexion at the level of the A2 and A4 annular pulleys as an indicator of tendon bowstringing. A distance between the flexor tendon and phalanx greater than 1.0 mm was interpreted as positive for a pulley injury. US findings were compared with those of magnetic resonance imaging. Surgical correlation was available in seven cases. Statistical analysis was performed by using analysis of variance, the Student t test, and the Bonferroni method.

RESULTS

US depicted 16 (100%) of 16 complete A2 pulley ruptures, nine (100%) of nine complete A4 pulley ruptures, six (86%) of seven surgically proved complete combined A2 and A3 pulley ruptures, and 15 (100%) of 15 incomplete A2 pulley ruptures. Measurement of distance between the flexor tendon and phalanx was significantly different among patient subsets without pulley ruptures and those with incomplete, complete, or complete combined pulley ruptures (P <.001). The sensitivity of US for depiction of finger pulley injuries was 98%, and specificity was 100%.

CONCLUSION

Dynamic US allows excellent depiction of finger pulley injuries in extreme rock climbers.

Finger injuries in extreme rock climbers. Assessment of high-resolution ultrasonography

Dynamic high-resolution ultrasonography findings obtained in 34 extreme rock climbers with finger injuries were compared with those in 20 healthy volunteers. Thicknesses of the flexor tendon and A-2 flexor tendon pulley system were measured at the base of the proximal phalanx. The distance between the tendon and phalanx was evaluated with the finger in extension and in forced flexion as a measure of bowstringing. Gliding ability of the flexor tendons was assessed during active and passive motion. Compared with healthy volunteers, climbers showed a significantly increased thickness of the flexor tendons and the flexor tendon pulley system but no impairment of the gliding mechanism. Only in climbers did the distance between tendon and phalanx increase from 0.14 cm (+/-0.07) during extension to 0.30 cm (+/-0.09) during forced flexion. In three climbers with complete A-2 pulley ruptures this distance was up to 0.51 cm (+/-0.15) during forced flexion. Clinically unsuspected synovial cysts, thickened joint capsules, fibrous tissue, or fluid collection were found only in climbers. We concluded that dynamic ultrasonography is a valuable tool for accurate assessment of early changes in "climber's finger." It provides useful information, especially in cases where clinical evaluation is difficult, and should be performed to select appropriate therapeutic management.

Musculoskeletal infections: US manifestations

One of the most important prognostic factors in patients with musculoskeletal infections is the delay in establishing therapy. Early diagnosis of septic arthritis requires analysis of joint fluid. Ultrasonography (US) is a rapid, portable, sensitive technique for confirming the presence of joint effusions. The study can be easily repeated for follow-up of lesions. US allows real-time guidance of fluid aspiration and can reduce the risk of contaminating other anatomic compartments, especially in the hands, wrists, and feet. Radiography provides complementary information and should be performed in conjunction with US. US is the imaging modality of choice for diagnosis of superficial abscesses. Dynamic compression with the US probe and color Doppler imaging can facilitate detection of superficial abscesses. US may help in the early diagnosis of osteomyelitis by demonstrating subperiosteal or juxtacortical fluid collections and by providing guidance for aspiration of these collections. Evaluation of osseous involvement requires additional imaging; a US examination with normal results does not allow exclusion of bone infection. US is not degraded by metallic artifact and may be useful in cases of osteomyelitis complicating metallic fixation in an extremity. After initial radiography, US can play an important role in the management of musculoskeletal infections.

Ultrasound in inflammatory disease

US may be used effectively to diagnose and treat a wide range of musculoskeletal inflammatory conditions. It is likely that its usage will increase with regards to such conditions especially in the management of rheumatology clinic patients.

Tendon and nerve sonography

The refinement of high frequency transducers has improved the ability of ultrasound (US) to detect fine textural abnormalities of tendons and nerves and to identify a variety of pathologic conditions. Characteristic echotextural patterns, closely resembling the histologic ones, are typically depicted in these structures using high US frequencies. In tendon imaging, US can identify tendon dislocations, degenerative changes, differentiate partial from complete tears and determine whether the patient has to be treated surgically or conservatively. A spectrum of findings in inflammatory conditions, including paratendonitis and tenosynovitis, and tendon tumors also can be detected. In nerve imaging, US can support clinical and electrophysiologic testing for detection of compressing lesions caused by nerve entrapment in a variety of osteofibrous tunnels of the limbs and extremities. Nerve tears and tumors also can be diagnosed. Overall, US is an effective technique for imaging tendons and nerves.

Applications of musculoskeletal sonography

To successfully examine the musculoskeletal system sonographically, one must understand the normal musculoskeletal anatomy and function and be aware of the abnormal processes that affect the musculoskeletal structures. The goal of this review article is to provide a systematic approach to sonographic examination of the musculoskeletal system. The general sonographic appearances of normal and abnormal muscles, tendons, ligaments, bursae, and nerves are reviewed. The article then applies this general information to specific clinical applications by reviewing the normal anatomy of and specific pathologic conditions that affect the shoulder, elbow, hand, wrist, hip, knee, ankle, and foot.

Diagnostic ultrasound of the hand and wrist

To assess the efficacy, role, and limitations of diagnostic ultrasound in the hand and wrist, the results of 98 examinations performed for a variety of surgical conditions were retrospectively analyzed. Ultrasound was shown to be reliable in evaluating radiolucent foreign body, tendon rupture versus tendon adhesion, tendinitis, peritendinitis, and ganglion cyst (specificity, 1; positive predictive value, 1). A correct suggestion of soft tissue mass histology was offered in six of eight operated cases. Tumor size and extent was accurately assessed in all but one case. The observed limitation of ultrasound was a small false negative rate in each category, which related to a variety of factors, including operator dependence, resolution threshold in the submillimeter range, image degradation due to postoperative edema, a narrow field of view, and one instance of indiscrete tumor margination. More work is needed to determine the role (if any) of ultrasound in the evaluation of peripheral nerve, triangular fibrocartilage, dorsal carpal ligament, and bone pathology.

Musculoskeletal ultrasound

Ultrasound is an extremely useful and versatile method of assessing soft tissue abnormality in rheumatological conditions. It is best performed as an extension of clinical examination. Ultrasound has the advantage of not only being able to demonstrate abnormalities but also allows transducer compression of those abnormalities to see if it reproduces the patient's characteristic symptoms. It is likely to find even greater use in the clinical setting over future years. In the near future skeletal ultrasound should develop into an essential tool for the extension of physical examination in rheumatology practise. It hopefully will become as vital to a rheumatologist as echocardiography is to a cardiologist. This will however require clinicians to be prepared to undergo sufficient training in order to avoid diagnostic errors. Probably it will only be at that time, when skeletal ultrasound has become a fundamental part of rheumatological diagnosis, that its full potential will be realized.

Dactylitis in patients with seronegative spondylarthropathy. Assessment by ultrasonography and magnetic resonance imaging

OBJECTIVE

To establish by means of ultrasound and magnetic resonance imaging (MRI) the role of tenosynovitis and arthritis in determining the "sausage-like" aspect of finger dactylitis and to compare the results of the 2 examinations.

METHODS

Twelve dactylitic fingers and their corresponding normal contralateral fingers belonging to 10 patients who met the Amor criteria for the diagnosis of seronegative spondylarthropathy (SpA) were studied by ultrasonography and MRI.

RESULTS

MRI revealed a significant increase in the volar bone-to-skin distance in dactylitic fingers with respect to that of the normal contralateral fingers (P < 0.001). This increase was due to distension of the flexor synovial sheaths (P < 0.00001) by fluid collection. Peritendinous soft tissues were not involved, since these were found to be significantly thicker in the normal fingers (P < 0.05). Of the 36 joints of the 12 dactylitic fingers, only 1 showed capsule distension. Using MRI as the "gold standard," ultrasonography showed a 100% sensitivity and specificity for flexor tenosynovitis, but lacked sensitivity for joint involvement because it failed to reveal joint capsule distension in the only joint involved. Similarly, physical examination showed a 100% sensitivity and specificity for flexor sheath involvement.

CONCLUSION

Dactylitis is due to flexor tenosynovitis. Enlargement of the finger joint capsule is not an indispensable condition for the "sausage-like" feature. Physical examination is a sufficient method for the diagnosis of dactylitis.

Finger tendon involvement in rheumatoid arthritis. Evaluation with high-frequency sonography

OBJECTIVE

To characterize finger tendon involvement in patients with rheumatoid arthritis (RA).

METHODS

The finger tendons of 20 RA patients were studied by ultrasonography using a high-frequency (13-MHz) transducer.

RESULTS

Eighteen patients (90%) showed finger tendon abnormalities: widening of the flexor tendon sheath (80%), loss of the normal fibrillar echotexture (60%), irregularity of the extensor (30%) and flexor (50%) tendon margins, tendon tear (10%), synovial cyst (20%).

CONCLUSION

High-frequency sonography is helpful in assessing even minimal finger tendon lesions in RA patients.

Dactylitis also involving the synovial sheaths in the palm of the hand

Images

Closed flexor tendon rupture in the palm: an unusual but predictable clinical entity

Closed intratendinous ruptures of flexor tendons are uncommon. Two such cases that occurred within the lumbrical origin are reported. Accurate history taking and clinical examination usually enable the site of rupture to be determined. Ultrasound examination can also help to localize the site. The role of the lumbrical, extrinsic flexors and trauma in the aetiology of the rupture are discussed.

Sonographic findings in examination of digital ganglia: retrospective study

A retrospective sonographic study of soft tissue masses of the hand was undertaken. A spherical fluid-filled structure with a well-defined wall was seen in 13 patients and the cases were diagnosed as ganglia. This diagnosis had been generally suspected clinically in the presence of a firm nonpainful lump. This study indicates that ultrasound is a valuable diagnostic tool for the study of soft-tissue masses of the hand and in the differential diagnosis of other soft tissue lesions, such as pigmented villonodular synovitis or tenosynovitis.

Hide and seek: pre-operative ultrasonic localization of non radio-opaque foreign bodies

Ultrasound has long been used as a diagnostic and therapeutic tool in surgery. We have extended its use to hand surgery, where is has several applications. Non radio-opaque foreign body extraction is invariably a frustrating exercise of 'hide and seek'. Accurate pre-operative localization with ultrasound illustrating size, shape, depth, soft tissue and bony relationships can ensure rapid and complete removal. Several cases are presented to demonstrate the use of ultrasound for the detection of non radio-opaque foreign bodies. The technique used will be described. We feel pre-operative localization by ultrasound is a useful technique to assist with the removal of non radio-opaque foreign bodies.

Use of sonography in the early detection of suppurative flexor tenosynovitis

Eighteen patients with swollen fingers suggesting acute suppurative tenosynovitis were studied by ultrasonography. All patients received intravenous antibiotics. Twelve patients required surgical drainage. Eleven of 12 patients had sonographic evidence of both a swollen tendon and fluid in the flexor sheath. Eleven of the 12 patients operated on had purulent fluid in the flexor sheath. Four of the operative cases were culture positive and four were culture negative. All six patients treated only with antibiotics had swollen tendons, but five of the six had no sonographic evidence of fluid in the flexor sheath. All patients had a full recovery. Sonographic evidence of fluid in the flexor sheath is a useful sign in the early diagnosis of acute suppurative flexor tenosynovitis.