Median Nerve Force Tendon

Septic arthritis of the hip in a limping three-year-old child with mild hip pain. a Longitudinal US scan reveals a small effusion with inho-mogeneous echogenicity and synovial thickening.Metaphyseal bone erosion is present (large white arrow). b X-ray in the same patient confirms the soft-tissue swelling around the involved joint, suggestive of effusion (empty white arrows), and bone erosion (small white arrow)

Hemophilia Bone Scan

Transient synovitis in a five-year-old child with similar clinical presentation to that of the patient in Fig. 5.40. a Frontal radiograph shows capsular swelling (empty white arrows). b US detects increased capsule-to-bone distance (calipers) related to joint effusion and to synovial thickening (*). c Power Doppler US demonstrates absence of intrasynovial increased flow

5.10 Hemophilic arthropathy

Hemophilia is an X-linked recessive bleeding disorder, due to deficiency or absence of blood-clotting factors. It is a disease almost exclusively found in males.Women are asymptomatic carriers and rarely may have acquired hemophilia (immunological origin). Hemorrhagic events may occur from the first years of life and can take place anywhere, although the musculoskeletal system is the preferred target organ.

US is useful to assess the early stages of hemo-philic arthropathy, as it shows synovial proliferation and initial cartilaginous damage [65,66], not detectable radiologically.

US is also fundamental both for hemorrhage monitoring and evaluation of the response to treatment. The most characteristic clinical manifestation of hemophilia is recurrent hemarthrosis, with secondary chronic synovitis and arthropathy. The knee and elbow are the most commonly involved joints. Recent bleeding appears echogenic, related to the high reflectivity of fresh blood. Later, 48-72 hours after the hem-orrhagic event, a progressive decrease in the echogenicity occurs, following blood cell lysis, and the effusion gradually becomes anechoic [16]. Bleeding may occur also in synovial bursae (Fig. 5.42).

Recurrent hemarthrosis can precociously induce villous hyperplasia of the synovium (Fig. 5.43) and,sub-sequently, a characteristic hemophiliac arthropathy.

Spontaneous bleeding into the muscle is common and may involve any muscle, even in the absence of trauma. The forearm, quadriceps, calf, and iliopsoas are most often involved, the latter having particularly insidious clinical presentation (Fig. 5.44). US evaluation performed within 24-48 hours from symptom onset of the hemorrhage may not be indicative, because recent bleeding usually appears hyperechoic, but sometimes may be isoe-choic compared to muscle echogenicity [16]. Later on, the hematoma appears as an anechoic intramuscular area with posterior enhancement.

Bursa Patellaris
Young male with severe hemophilia. Longitudinal US scan of the anterior aspect of the knee demonstrating enormous distention of the prepatellar bursa by echogenic effusion due to recent bleeding intra-bursal bleeding
Fig. 5.43

Recurrent hemarthrosis in a patient with hemophilia A.Trans-verse US scan of the knee depicts the suprapatellar synovial recess which appears distended from abundant anechoic effusion, related to previous hemarthrosis. Synovial villous thickening is also depicted

5.11 Primary and secondary nerve disorders

In several rheumatologic disorders, such as rheumatoid arthritis, polyarteritis nodosa,Wegen-er's granulomatosis, Churg-Strauss and Sjogren syndrome, one of the clinical landmarks of vas-culitis is the appearance of neurological findings [67,68]. From the pathophysiological point-of-view, the vasculitis-related neuropathy affects large nerve trunks, producing a multifocal degeneration of fibers as a result of necrotizing angiopathy of small nerve arteries, the so called "multiple mononeu-ropathy" [69]. In these patients, the neuropathy does not correlate with disease parameters (disease activity, rheumatoid factor and functional and radiological scores), and there is sequential involvement of individual nerves both temporally and anatomically [70]. Nerve conduction velocities are

Sjogren Syndrome And Nerve Problems Easy Scan Neuropathy

Patient with severe hemophilia. a Transverse non-contrast computed tomography (CT) scan detected an old iliopsoas hemorrhage, evident as an intramuscular area of decreased density (*). b Transverse sonogram in the same patient depicts the echofree appearance of the muscle hemorrhage (*). c Echographic reexamination just after sudden recurrence of pain shows the presence of recent bleeding (empty white arrow), which appears echogenic and easy to discriminate from the mostly reabsorbed previous hemorrhage (*)

usually not markedly reduced from normal, provided that the compound nerve or muscle action potential is not severely reduced in amplitude [71]. Although multiple mononeuropathy is the most common manifestation, nerve entrapment syndromes may also occur at sites where nerves pass in close proximity to either a synovial joint (i.e. cubital tunnel, tarsal tunnel, Guyon tunnel) or one or more synovial-sheathed tendons (i.e. flexor tendons at the carpal tunnel, flexor hallucis longus at the tarsal tunnel) or para-articular bursae (i.e. iliop-soas bursa at the hip). The clinical evaluation of nerves is often made difficult in these patients by symptoms resulting from pain in the joints and limitations of movement, US imaging can contribute in distinguishing entrapment neuropathies related to derangement of joints and tendon abnormalities (joint effusion, synovial pannus, tophi)

from non-entrapment neuropathy. This is based on the fact that multiple mononeuropathy does not lead to an altered morphology of the affected nerve, whereas entrapment neuropathies do.

Among the individual sites of nerve entrapment, the carpal tunnel is the most commonly involved in patients with rheumatologic disorders. A median nerve area of > 9 mm2 or >10 mm2 calculated at the point of maximum nerve swelling -being just proximal to the edge of the retinaculum or at the scaphoid-pisiform level - has been reported as the best criterion for the diagnosis of carpal tunnel syndrome [72-75]. US also has value in follow-up after surgical release of the retinaculum. After decompression, the appearance of the median nerve may improve even before any definite sign of functional recovery at electrophysiological examination [76].

In rheumatoid arthritis, median nerve compression most often results from amyloid deposits, ganglion cysts or, more commonly, from hyper-trophied tenosynovitis of the flexor digitorum tendons (Fig. 5.45). In general, synovial sheath effusion facilitates visualization and differentiation of the individual flexor tendons within the carpal tunnel [77]; dynamic scanning on transverse planes during repetitive flexion and extension movements of the fingers may aid in the differentiation between tendons and echogenic synovium and may reveal restricted passive motion of the compressed nerve beneath the retinaculum. In cases of mild tendon effusion, US scanning should be extended to levels more proximal and distal relative to the carpal tunnel because most synovial fluid may accumulate outside the tunnel.

More rarely, deep synovitis from the radiocarpal and midcarpal joints may lead to anterior displacement of the flexor tendons and compression of the median nerve against the retinaculum. Anomalous bone (lunate) projecting inside the deep portion of the tunnel (often associated with flexor tenosynovitis), can be recognized as the cause of nerve compression as well. This may be secondary to dorsal intercalated instability of the wrist (DISI) following arthritic derangement of the carpal joints and intrinsic carpal ligaments (Fig. 5.46). In these cases, US shows the nerve compressed against the retinacu-lum by a rounded bony structure bulging from the floor of the carpal tunnel reflecting the displaced lunate. In patients with rheumatoid arthritis and carpal tunnel syndrome, US can help to guide steroid injection within the flexor tendon sheath [78].

At the medial elbow, the ulnar nerve passes in the condylar groove - an osteofibrous tunnel between the olecranon and the medial epicondyle covered by the Osborne retinaculum - and then in the cubital tunnel - a narrow passageway below the aponeurotic arcade between the ulnar and the humeral heads of the flexor carpi ulnaris [77]. Nerve cross-sectional area > 7.5 mm2 at the epitrochlear level is considered the threshold value for cubital tunnel syndrome [79]. More recently, a European study based on the normal population revealed that the mean cross-sectional area of this nerve is 7.9 mm2 [80]. In patients with overt syn-ovitis of the elbow joint, the nerve may be compressed at the condylar groove or, more often, at the edge of the aponeurosis of the flexor carpi ulnaris by synovial tissue arising from the floor of the tunnel (Fig. 5.47).

Power Doppler

Carpal tunnel syndrome in tenosynovitis of the flexor tendons.a Long-axis US image of the median nerve at the distal radius demonstrates fluid (*) surrounding the flexor tendons (fit), resulting in palmar displacement and compression of the median nerve (MN) at the entrance of the tunnel.(b, c) Correlative short-axis US images of the median nerve obtained (b) at the distal radius and (c) at the proximal tunnel level (scaphoid-pisiform level) show an abnormally enlarged nerve (MN) with loss of the fascicular echotexture which becomes flattened behind the flexor retinaculum (arrows). Note the convex profile of the retinaculum

Carpal tunnel syndrome in tenosynovitis of the flexor tendons.a Long-axis US image of the median nerve at the distal radius demonstrates fluid (*) surrounding the flexor tendons (fit), resulting in palmar displacement and compression of the median nerve (MN) at the entrance of the tunnel.(b, c) Correlative short-axis US images of the median nerve obtained (b) at the distal radius and (c) at the proximal tunnel level (scaphoid-pisiform level) show an abnormally enlarged nerve (MN) with loss of the fascicular echotexture which becomes flattened behind the flexor retinaculum (arrows). Note the convex profile of the retinaculum

Fig. 5.46 a-d

Carpal tunnel syndrome in long-standing rheumatoid arthritis and dorsal intercalated instability of the wrist (DISI).a Schematic drawing over the long axis of the wrist illustrates the mechanism of nerve compression. b Longitudinal US image over the proximal carpal tunnel shows the median nerve (MN) and the flexor tendons (ft) compressed by the prominent lunate (i).Within the carpal tunnel,the lunate assumes a crescentic profile (arrowheads) due to the volar rotation of its convex articular surface. c, d Correlative (c) longitudinal fat-suppressed T2-weighted and (d) transverse T1-weighted MR images reveal the abnormal position of the lunate (arrows) and the median nerve (arrowheads) compression against the transverse carpal ligament. Cap = capitate; * = effusion

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