Clinical Evaluation of the Painful Wrist and Hand



 

FIGURE 13.35 Synovial cyst. T2-weighted fat-suppressed A: axial and B: coronal MR images show a polylobulated mass with high signal intensity with a linear component (arrowhead) that extends to the anterior elbow joint. C: T1-weighted fat-suppressed MR image after the administration of intravenous contrast shows low signal intensity within the lesion verifying that it is a simple fluid collection without solid components.


 

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FIGURE 13.36 Primary synovial osteochondromatosis. A: T1-weighted coronal, B: T1-weighted sagittal, and C: T2-weighted fat-suppressed axial MR images through the elbow show multiple, uniformly sized intra-articular ossified bodies (curved arrows) evenly distributed throughout the joint. There is superimposed degenerative change in the radiocapitellar (arrowhead) and ulnotrochlear joints (arrow).


 

MRI is the imaging method of choice for the diagnosis, surgical planning, and evaluation of recurrence. Although not pathognomonic, MRI features in PVNS provide the diagnosis in over 95% of cases. Clumps of hemosiderin-laden macrophage deposits demonstrate low signal intensity on T1- and T2-weighted images as a result of the paramagnetic effects of the iron in the ferric (3+) state. This is the most reliable diagnostic feature. Gradient imaging, like in the case of hemophilia, may further enhance imaging of these findings as a result of the magnetic susceptibility effects (154, 155). A large joint effusion is usually present but is nonspecific in nature.


Less characteristic MRI findings in PVNS include bone erosions and extra-articular spread of lesions. T2-hyperintense signal may also be seen as the result of subchondral cysts or reactive bone marrow edema. Additionally, focal deposits of lipid-laden macrophages can result in fat signal intensity.


In addition to facilitating the diagnosis, MRI is also useful in characterizing the extent of disease by the detection of extra-articular spread as well as assessing the status of the adjacent ligamentous and fibrocartilaginous structures. Common extra-articular sites of spread include the popliteus tendon sheath, posterior to the posterior cruciate ligament, the semimembranosus bursa, and previous arthroscopy portals.


The treatment of diffuse PVNS is a complete synovectomy. The high recurrence rate, reported to range from 33% to 46%, precludes localized surgical treatment. The exact reasons for such a high rate of recurrence is unclear but may be related to the difficulty in performing a complete synovectomy. A recent hypothesis also suggests a high rate of recurrence resulting from the failure to identify and resect extra-articular lesions. The latter hypothesis, if correct, increases the importance of carefully addressing the bursa and tendon sheaths about the joint (156).


Focal Nodular Synovitis


Localized nodular synovitis, like its more diffuse counterpart, PVNS, is a rare synovial inflammatory disorder whose etiology is uncertain. Although this disorder shares similar histopathologic characteristics and patient population as PVNS, the MRI characteristics of the localized form are distinct from PVNS. Moreover, the reader should be aware that it is of paramount importance to distinguish these two entities because their surgical planning, treatment, and response to treatment differ dramatically (154, 158, 159).


The MRI characteristics of localized nodular synovitis vary. The classic appearance is a rounded or ovoid solitary lesion that demonstrates different degrees of low signal on T1- and T2-weighted images depending on the concentration of hemosiderin occupying the lesion. The lesion typically is more conspicuous on gradient imaging as a result of the paramagnetic effect of iron molecules in the ferric state. There is usually heterogeneous enhancement after the intravenous administration of contrast material, which likely relates to the rich capillary network occupying the fibrous stroma (154).


The most commonly affected regions are tendon sheaths about small articulations of the fingers and toes. When intra-articular disease is present, it is almost always localized to the knee. Specifically, the most common location is the infrapatellar (Hoffa’s) fat pad. Other affected areas about the knee are the suprapatellar pouch and the intercondylar notch.


The importance of distinguishing localized nodular synovitis from PVNS cannot be overemphasized. MRI of PVNS usually shows a more exuberant pattern of hemosiderin deposition manifested as frond-like low-signal irregularities residing within the joint spaces. This finding is absent in localized nodular synovitis; in fact, only a small portion of the synovium is involved. In addition, PVNS-induced masses insinuate themselves throughout the articulation resulting in marked constriction. The localized form manifests as a solitary mass, which grows outward and may have an associated pedicle. In a recent study by Huang et al. (158), it has been noted that when the lesion grows in excess of 5 cm, knee extension is more likely to be restricted. Joint effusions in this disease are usually small or absent.


The treatment of choice for localized nodular synovitis is local excision of the solitary mass. When compared with PVNS, localized nodular synovitis never requires a total synovectomy and the rate of recurrence is exquisitely low, usually less than 5%. Excision can usually be accomplished with arthroscopic guidance; however, an open procedure may be warranted in certain instances.


Amyloidosis


Amyloidosis is an infiltrative disorder characterized by the deposition of a pathologic proteinaceous substance (amyloid) in various tissues and organs in the body ultimately resulting in physiological derangement. Amyloidosis is further characterized into multiple subtypes depending on the chemical nature of the protein that makes up the amyloid fibril. Fifteen different biochemical subtypes of amyloid have been described to date. The histopathologic appearance, however, is uniformly characterized by apple green birefringence of Congo red-stained amyloid on polarized light microscopy irrespective of the biochemical subtype. The most common biochemical subtype in amyloid arthropathy is B2 microglobulin (160162).


Amyloid arthropathy has been well documented as a complication in patients on long-term hemodialysis. This disorder develops as a result of accumulation of high concentrations of the normal serum protein B2 microglobulin in the synovium, bone, and soft tissues about the joint. Although amyloid deposition can be histologically documented in the joints of patients on short-term hemodialysis, radiographic manifestations usually occur at least 5 years after treatment begins. Joint involvement is bilateral and fairly symmetric and although any joint may be involved, this entity has a predilection for the shoulders, wrists, hips, and knees but can occur in any articulation. MRI characteristics of amyloid are not unlike other deposition diseases that involve the synovium (160162).


MRI demonstrates soft tissue nodules of low to intermediate signal on all pulse sequences with associated joint effusions. These nodules are most commonly seen around the elbow, hand, and wrist. In fact, amyloid deposition has been implicated as the cause of carpal tunnel syndrome in patients on long-term dialysis.


Additionally, discrete periarticular intraosseous lytic foci and subchondral cystic changes are also a characteristic finding on conventional radiographs. On MRI, these lesions are dark on T1-weighted images and dark, bright, or intermediate signal on T2-weighted images. The exact nature of these lesions is not known. Some experts speculate that these lesions may represent focal amyloid deposits. Others believe these are synovial fluid collections that develop as a result of extrinsic compression from the pericapsular soft tissue deposits.


Involvement of fibrocartilaginous structures has also been documented on MRI. Specifically, thickening of the supraspinatus and infraspinatus tendons of the rotator cuff as well as the iliofemoral portion of the hip capsule have been reported. Tendon rupture or tears, however, are not associated with this disease (160162).


Tumors and Tumor-like Disorders of Soft Tissues


The evaluation of soft tissue tumors has been revolutionized by the advent of MRI with its excellent soft tissue contrast and multiplanar imaging capabilities. The primary objectives of the imaging evaluation of soft tissue lesions include the detection of the suspected lesion and the formulation of a diagnosis or set of differential considerations. Despite sophisticated imaging techniques such as MRI, the imaging appearance of the majority of soft tissue lesions remains nonspecific with a correct histologic diagnosis reached on the basis of imaging studies alone in only approximately one fourth to one third of cases (163166). The majority of soft tissue lesions in the upper extremity are nonspecific to this region. Most of the lesions that do show a predilection for the upper extremity are unique to the hand and wrist. Although a complete discussion of soft tissue lesions is outside the scope of this work, a brief discussion of lesions that have characteristic MRI findings or are relatively specific to the region of the elbow follows. With regard to the former, often the tissue of origin in soft tissue lesions can be surmised by signal characteristics, morphology as well as proximity to adjacent structures. In addition, the soft tissue elements common to most regions of the body include fat, vascular structures, nerve tissue, muscle, and synovium.


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FIGURE 13.37 Intramuscular lipoma. A: Coronal and B: axial T1-weighted MR images through demonstrate a high-signal–intensity mass (curved arrow) within the supinator muscle.


 

Lipoma


Although not specific to the elbow, the lipoma is the most common soft tissue tumor (Fig. 13.37). It is a benign lesion composed of mature adipose tissue. Soft tissue lipomas are categorized by anatomic location as either superficial (subcutaneous) or deep, the former being much more common. After the trunk, the shoulder and upper arm is the most common location. They are unusual in the hand and foot. These lesions present in middle age (fifth and sixth decades of life), although there is a wide spectrum of age at presentation. They generally present as painless, slow-growing masses. On physical examination, they are soft, usually encapsulated, with a distinct lobular pattern.


The MRI characteristics are those of a well-defined mass with signal characteristics that parallel fat on all pulse sequences. There is no discernible enhancement after the administration of intravenous gadolinium (147).


Differentiation from low-grade liposarcoma can be challenging. The presence of thick, irregular internal septation, internal nodularity, or patchy nonadipose elements within the lesion suggest possible malignancy. Internal enhancement after intravenous gadolinium administration may also correlate with low-grade malignancy.


Vascular Lesions


The angiomatoses are a common cause of soft tissue mass. Included in this category are hemangiomas and lymphangiomas, glomus tumors, hemangioendotheliomas, hemangiopericytomas, angiosarcomas, and Kaposi’s sarcoma (165). The classification of these lesions is somewhat controversial with very different approaches discussed in the literature. Both systems are presented, the first in the setting of elbow lesions and the second approach discussed in the setting of finger lesions.


The first approach considers hemangioma one of the most frequent soft tissue tumors and advocates a classification system based on the type of vascular channel that dominates the histologic appearance. Capillary hemangiomas are comprised solely of capillaries and are generally located in the superficial soft tissues. If histologic analysis shows widely dilated capillaries, the tumor is called a cavernous hemangioma. Cavernous hemangiomas predominate in the deep soft tissues and commonly contain calcifications in the form of phleboliths. If a vascular tumor has thicker walls and contains smooth muscle cells, it is called a venous hemangioma. Venous hemangiomas are often deep and involve the muscles of the extremities or retroperitoneum (Fig. 13.38). Slow blood flow typifies venous hemangiomas, and phleboliths may be seen. When histologic analysis shows abnormal communication of arteries and veins, the term arteriovenous hemangioma or arteriovenous malformation is often used. This type of lesion is often associated with shunting of blood and high blood flow (167170).


Based on this classification system, MRI findings of such vascular lesions typically show poorly marginated lesions comprised of tubular structures. These structures are isointense relative to muscle on T1-weighted MR images. Areas of high signal intensity can also be seen on T1-weighted MR images that could be related to interposed fat or to slow-flowing blood. Fat overgrowth can be encountered in vascular neoplasms and, in some cases, can be so prominent as to be indistinguishable from lipoma. On T2-weighted MR images, soft tissue hemangiomas reveal a well-marginated mass with very high signal intensity in areas of vascular components, whereas regions of adipose tissue are intermediate intensity and isointense to subcutaneous fat. In some cases, pathologic subtypes can be recognized by MRI. A mass composed primarily of large vascular spaces suggests a cavernous hemangioma, whereas a venous hemangioma shows predominantly serpentine vascular channels. Hemangiomas show prominent enhancement after intravenous administration of gadolinium. Hemorrhage also occurs in hemangiomas. Phleboliths, as previously noted, are also commonly encountered but better identified by radiographs or computed tomography. On MRI, they appear as low-signal–intensity foci on all pulse sequences. If the hemangioma is located adjacent to bone, periosteal reaction can occur (167170).


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FIGURE 13.38 Vascular lesion. A: T2-weighted fat-suppressed axial and B: T1-weighted coronal MR images through the forearm demonstrate a large intramuscular mass with serpentine areas of high signal intensity and interspersed fat on the T1-weighted images. Based on the location and the dilated nature of the tubular high-signal–intensity structures (arrowheads), the diagnosis of venous hemangioma was suggested and confirmed on pathology. C: T1-weighted fat-suppressed axial MR image after the administration of intravenous contrast shows enhancement of the tubular structures (arrowheads) consistent with the vascular nature of the lesion.


 

Neurogenic Lesions


Neoplasms of neurogenic origin are not uncommon soft tissue tumors. They account for approximately 12% of all benign and 8% of all malignant soft tissue neoplasms (167172). In many cases, imaging characteristics suggest aneurogenicorigin. These features include the ability to visualize a nerve entering or exiting the lesion as well as MRI signal characteristics both before and after the intravenous administration of gadolinium. Benign peripheral nerve sheath tumors are typically divided into two major groups: schwannoma and neurofibroma, schwannoma slightly less common than neurofibroma.


Schwannomas are found commonly in the cutaneous nerves of the head and neck and the flexor surfaces of the extremities, especially the peroneal and ulnar nerves. They are slow-growing, nonaggressive neoplasms that present as painless masses (usually less than 5 cm in size) without neurologic symptoms. They are solitary in the vast majority of cases. In 5% of cases, they can be plexiform and associated with von Recklinghausen disease. Pathologically, a schwannoma has a true capsule composed of perineurium. When large nerves are affected, the tumor is eccentric with the nerve displaced to the periphery of the mass. Histologically, schwannomas are composed of intermixed Antoni A (cellular and arranged in short bundles or interlacing fascicles) and Antoni B (less cellular and organized with more myxoid component) areas. Degenerative changes such as cyst formation, calcification, hemorrhage, hyalinization (fibrosis) can be seen in schwannomas, which are then labeled ancient schwannomas (165, 173).


Neurofibromas are divided to solitary (the vast majority) or those associated with neurofibromatosis 1 (von Recklinghausen disease). Neurofibromas, similar to schwannomas, are slow-growing, painless masses located in superficial tissues and often less than 5 cm in size. In contradistinction to schwannoma, however, these lesions lack a capsule. Pathologically, these lesions cannot be separated from the nerve. Microscopically, they contain interlacing bundles of elongated cells with wavy, darkly staining nuclei without Antoni A and B areas as noted in schwannoma (165, 173).


With MRI, these lesions show a fusiform shape, and a nerve is often identified entering or exiting the mass as a tubular structure (165, 174, 175). Long-axis MRI is optimal to illustrate this appearance. In theory, distinction between neurofibroma and schwannoma should be possible with MRI. Classically, the nerve is eccentric to the mass in schwannoma rather than being central to it or obliterated by it in the setting of neurofibroma. Some studies report the ability to identify the exact nerve/mass relationship in 65% of cases (175). Some neurogenic tumors have a discrete margin, and thin, low-signal–intensity rim representing a fibrous pseudocapsule (175). This is more frequent with schwannoma. Many neurogenic tumors also have a peripheral rim of fat (176). This may result from their origin in the neurovascular bundle and subsequent centripetal growth allowing the rim of surrounding fat to remain intact. This finding is referred to as the “split-fat” sign and is seen with both schwannoma and neurofibroma. MR images of neurogenic neoplasms show signal intensity similar to or slightly higher than that of muscle on T1-weighted images. Typically, there is high signal intensity on corresponding T2-weighted images with variable heterogeneity. In some cases, a central low-signal–intensity region on T2-weighted images with a surrounding rim of high signal intensity can be identified within the lesion (Fig. 13.39). This is referred to as the target sign and corresponds pathologically to central fibrous components and peripheral myxomatous elements within the lesion (174, 177, 178). The target sign is most frequently encountered in neurofibromas. Careful inspection of intermediate- to low-signal–intensity areas of the lesions on proton density- and T2-weighted images often reveal small ring-like areas with slightly higher signal intensity in their periphery. This is the so-called fascicular sign and the oretically reflects fascicular bundles of tissue seen in both neurogenic tumors and normal nerves (165). Enhancement of neurogenic lesions after the administration of intravenous contrast material is both variable and nonspecific (Fig. 13.40). Both benign and malignant peripheral nerve sheath tumors can show minimal to marked enhancement either focally or diffusely (179). Muscle atrophy can be associated with neurogenic neoplasms. It is usually noted in a distal muscle group and is manifested as increased amounts of fat within the muscle on T1-weighted images. Stull et al. (179) noted distal muscle atrophy in 23% of peripheral neurogenic tumors.


Cat Scratch Disease


Cat scratch disease is an infectious disorder that occurs frequently in children and adolescents. The entity is characterized by lymphadenitis and the formation of pustules or papules after the scratch of an animal, usually a cat. In most instances, the diagnosis is facilitated by the characteristic clinical history.


After an incubation period of 7 to 12 days, one or more red papules develop at the site of cutaneous inoculation, often within the line of the previous scratch. They persist until the development of lymphadenopathy, which generally occurs in 1 to 4 weeks. Chronic lymphadenitis is the hallmark of cat scratch disease. Sites most frequently involved include the axillary, cervical, submandibular, preauricular, epitrochlear, femoral, and inguinal lymph node groups. On MR images, an ill-defined mass with surrounding edema in the epitrochlear region of the elbow suggests epitrochlear lymphadenopathy. On T2-weighted images, the lymph nodes are high signal but have a nonspecific appearance (Fig. 13.41) (110, 180, 181). Involvement of more than one node group occurs in 10% to 20% of cases. Affected nodes are often tender, red, and indurated. Between 10% and 40% of nodes eventually suppurate with sinus tract formation to the skin surface. The duration of enlargement is 4 to 6 weeks, in some cases persisting up to 12 months. The cause is by a pleomorphic Gram-negative bacillus (Bartonella henselae). This disease was first described in 1950 by Debre et al. The diagnosis is generally made on clinical grounds by verifying the presence of at least three of the following four features (diagnostic criteria): (i) history of exposure to animal scratch; (ii) demonstration of dermal or ocular inoculation; (iii) presence of a single or regional area of lymphadenopathy; and (iv) a positive cat scratch disease skin test. Other criteria include biopsy of the skin lesion or lymph nodes with demonstration of histopathologic findings characteristic of the disease (polymorphonuclear cells, inflammation with possible necrosis, clusters of epithelioid histiocytes) (182184).


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FIGURE 13.39 Schwannoma with target sign. A: T1-weighted, B: T2-weighted, and C: T1-weighted axial postintravenous contrast MR images show a large median nerve mass (arrowhead) with variable central signal intensity (curved arrow) consistent with the target sign.


 

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FIGURE 13.40 Stump neuroma. A: T1-weighted coronal MR image shows a forearm amputation in a patient presenting with stump pain. B: T2-weighted fat-suppressed axial and C: T1-weighted fat-suppressed postintravenous contrast axial MR images show an enlarged radial nerve lesion (curved arrow) that enhances. Subtle heterogeneous high signal is noted in the muscles of the stump.


 

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FIGURE 13.41 Cat scratch disease. A: T1-weighted axial and B: T2-weighted coronal MR images through the elbow show an elliptical mass (asterisk) with adjacent fluid collection (curved arrow). C: T1-weighted axial MR image acquired after the intravenous administration of contrast shows enhancement in the mass (asterisk) and confirms the presence of fluid collection (curved arrow). These findings are consistent with an enlarged epitrochlear lymph node with adjacent inflammatory fluid collection.


 

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