Emergency Radiology

, Volume 26, Issue 2, pp 227–240 | Cite as

Sonographic imaging of hand and wrist injuries: applications in the ER setting

  • Daniel HillmanEmail author
  • Matthew Rheinboldt
  • Andrew Petraszko
Pictorial Essay


Acute osseous and soft tissue injuries to the hand and wrist are a common cause for ER visitation. Though diagnostic assessment has historically remained the province of conventional radiography, CT and MRI, sonography is gaining increasing acceptance and utilization. Offering multiple inherent advantages as an imaging modality, ultrasonic assessment has proven its utility in the evaluation of ligamentous and tendinous carpal and digital injuries as well as infection and inflammation. In this review, we will initially discuss sonographic technique and relevant normal anatomical features. Illustrative examples of soft tissue and osseous injuries of the hand and wrist as well as complicated infections most likely to be encountered in the emergency setting will then be presented together with a discussion of their relevant clinical considerations and management.


Hand Wrist Ultrasound Trauma Tendon Ligament 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Hangiandreou N (2003) B-mode US: basic concepts and new technology. Radiographics 23:1019–1033CrossRefGoogle Scholar
  2. 2.
    Lin C, Nazarian L, O’Kane P et al (2002) Advantages of real-time spatial compound sonography of the musculoskeletal system versus conventional sonography. AJR 179:1629–1631CrossRefGoogle Scholar
  3. 3.
    Olubaniyi B, Bhatnagar G, Vardhanabhuti V et al (2013) Comprehensive musculoskeletal sonographic evaluation of the hand and wrist. J Ultrasound Med 32:901–914CrossRefGoogle Scholar
  4. 4.
    Olchowy C, Solinski D, Lasecki M et al (2017) Wrist ultrasound examination – scanning technique and ultrasound anatomy. Part 2: ventral wrist. J Ultrasound 17:123–128Google Scholar
  5. 5.
    Teefey S, Middleton W, Boyer M (2000) Sonography of the hand and wrist. Semin Ultrasound CT MRI 21(3):192–204CrossRefGoogle Scholar
  6. 6.
    Martinoli C, Bianchi S, Nebiolo M, Derchi LE, Garcia JF (2000) Sonographic evaluation of digital annular pulley tears. Skelet Rad 29:387–391CrossRefGoogle Scholar
  7. 7.
    Plotkin B, Sampath S, Sampath S et al (2016) MR imaging and US of the wrist tendons. Radiographics 36:1688–1700CrossRefGoogle Scholar
  8. 8.
    Kalson N, Malone P, Bradley R et al (2012) Fibre bundles in the human extensor carpi ulnaris tendon are arranged in a spiral. J Hand Surg Eur 37:550–554CrossRefGoogle Scholar
  9. 9.
    Chiavaras M, Jacobson J, Yablon C et al (2014) Pitfalls in wrist and hand ultrasound. AJR 203:531–540CrossRefGoogle Scholar
  10. 10.
    Choi S, Ahn J, Lee Y et al (2011) de Quervain disease: US identification of anatomic variations in the first extensor compartment with an emphasis on subcompartmentalization. Radiology 260:480–486CrossRefGoogle Scholar
  11. 11.
    Rousset P, Vuillemin-Bodaghi V, Laredo JD, Parlier-Cuau C (2010) Anatomic variations in the first extensor compartment of the wrist: accuracy of US. Radiology 257:427–433CrossRefGoogle Scholar
  12. 12.
    Daenen B, Houben G, Bauduin E et al (2004) Sonography in wrist tendon pathology. J Clin Ultrasound 32:462–469CrossRefGoogle Scholar
  13. 13.
    Vreju F, Ciurea M, Popa D et al (2016) Ultrasonography in the diagnosis and management of noninflammatory conditions of the hand and wrist. Med Ultrasound 18(1):90–95Google Scholar
  14. 14.
    Hoffman D, Adams E, Bianchi S (2015) Ultrasonography of fractures in sports medicine. Br J Sports Med 49:152–160CrossRefGoogle Scholar
  15. 15.
    Herneth A, Siegmeth A, Bader T et al (2001) Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiology 220:231–235CrossRefGoogle Scholar
  16. 16.
    DaCruz D, Taylor R, Savage B et al (1988) Ultrasound assessment of the suspected scaphoid fracture. Arch Emerg Med 5:97–100CrossRefGoogle Scholar
  17. 17.
    Senall J, Failla J, Bouffard J et al (2004) Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg [Am] 29:400–405CrossRefGoogle Scholar
  18. 18.
    Becciolini M, Bonacchi G (2015) Fracture of the sesamoid bones of the thumb associated with volar plate injury: ultrasound diagnosis. J Ultrasound 18:395–398CrossRefGoogle Scholar
  19. 19.
    Bianchi S, van Aaken J, Glauser T, Martinoli C, Beaulieu JY, Santa DD (2008) Screw impingement on the extensor tendons in distal radius fractures treated by volar plating: sonographic appearance. AJR 191(5):W199–W203CrossRefGoogle Scholar
  20. 20.
    Dowlen H, Roberton B, Owers (2012) Bilateral sequential closed traumatic wrist flexor tendon ruptures. J Hand Surg Eur 37(7):694–695CrossRefGoogle Scholar
  21. 21.
    Haavardsholm E, Ostergaard M, Ejbjerg B et al (2007) Introduction of a novel magnetic resonance imaging tenosynovitis score for rheumatoid arthritis: reliability in a multireader longitudinal study. Ann Rheum Dis 66(9):1216–1220CrossRefGoogle Scholar
  22. 22.
    Jeyapalan K, Bisson M, Dias J et al (2008) The role of ultrasound in the management of flexor tendon injuries. J Hand Surg Eur Vol 33:430–434CrossRefGoogle Scholar
  23. 23.
    Lee D, Robbin M, Galliott R et al (2000) Ultrasound evaluation of flexor tendon lacerations. J Hand Surg [Am] 25:236–241CrossRefGoogle Scholar
  24. 24.
    Corduff N, Jones R, Ball J (1994) The role of ultrasound in the management of zone 1 flexor tendon injuries. J Hand Surg (Br) 19:76–80CrossRefGoogle Scholar
  25. 25.
    Karabay N (2013) US findings in traumatic wrist and hand injuries. Diagn Interv Radiol 19:320–325PubMedGoogle Scholar
  26. 26.
    Chun K, Cho K (2015) Postoperative ultrasonography of the musculoskeletal system. Ultrasonography 34:195–205CrossRefGoogle Scholar
  27. 27.
    Freilich A (2015) Evaluation and treatment of Jersey finger and pulley injuries in athletes. Clin Sports Med 34(1):151–166CrossRefGoogle Scholar
  28. 28.
    Leddy J, Packer J (1977) Avulsion of the profundus tendon insertion in athletes. J Hand Surg [Am] 2(1):66–69CrossRefGoogle Scholar
  29. 29.
    Smith J (1981) Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx: case report. J Hand Surg [Am] 6(6):600–601CrossRefGoogle Scholar
  30. 30.
    Scalcione L, Pathria M, Chung C (2012) The athlete’s hand: ligament and tendon injury. Semin Musculoskelet Radiol 16(4):338–349CrossRefGoogle Scholar
  31. 31.
    Clavero JA, Golanó P, Fariñas O, Alomar X, Monill JM, Esplugas M (2003) Extensor mechanism of the fingers; MR imaging-anatomic correlation. Radiographics 23(3):593–611CrossRefGoogle Scholar
  32. 32.
    McMurtry J, Isaacs J (2015) Extensor tendons injuries. Clin Sports Med 34(1):167–180CrossRefGoogle Scholar
  33. 33.
    Marino J, Lourie G (2012) Boutonnière and pulley rupture in elite athletes. Hand Clin 28(3):437–445CrossRefGoogle Scholar
  34. 34.
    Rettig A (2004) Athletic injuries of the wrist and hand: part II—overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med 32(1):262–273CrossRefGoogle Scholar
  35. 35.
    Bachoura A, Ferikes AJ, Lubahn JD (2017) A review of mallet finger and Jersey finger injuries in the athlete. Curr Rev Musculoskelet Med 10:1–10CrossRefGoogle Scholar
  36. 36.
    Lopez-Ben R, Lee D, Nicolodi D (2003) Boxer knuckle (injury of the extensor hood with extensor tendon subluxation): diagnosis with dynamic US: report of three cases. Radiology 228(3):642–646CrossRefGoogle Scholar
  37. 37.
    Melone C, Polatsch D, Beldner S (2009) Disabling hand injuries in boxing: boxer’s knuckle and traumatic carpal boss. Clin Sports Med 28(4):609–621CrossRefGoogle Scholar
  38. 38.
    Hame S, Melone C (2000) Boxer’s knuckle in the professional athlete. Am J Sports Med 28(6):879–882CrossRefGoogle Scholar
  39. 39.
    Willekens I, Kichouh M, Boulet C, de Maeseneer M, Clarys JP, de Mey J (2015) Ultrasound follow-up of posttraumatic injuries of the sagittal band of the dorsal hood treated by a conservative approach. Eur J Radiol 84(2):278–283CrossRefGoogle Scholar
  40. 40.
    Alnaif N, Alrobaiea S, Azzi A et al (2018) Diagnosis of isolated extensor carpi radialis longus (ECRL) tendon avulsion fracture using ultrasound: a paradigm shift. Skelet Rad 47(2):155–159CrossRefGoogle Scholar
  41. 41.
    Jessa K, Hodge J (1997) Avulsion fracture of tendon of extensor carpi radialis longus: unknown mechanism. J Emerg Med 15(2):201–207CrossRefGoogle Scholar
  42. 42.
    DeLee J (1979) Avulsion fracture of the base of the second metacarpal by the extensor carpi radialis longus. A case report. J Bone Joint Surg Am 61(3):445–446CrossRefGoogle Scholar
  43. 43.
    Graham TJ (2012) Pathologies of the extensor carpi ulnaris tendon and its investments in the athlete. Hand Clin 28(3):345–356CrossRefGoogle Scholar
  44. 44.
    Inoue G, Tamura Y (1998) Recurrent dislocation of the extensor carpi ulnaris tendon. Br J Sports Med 32(2):172–174CrossRefGoogle Scholar
  45. 45.
    Starr H, Sedgley M, Means K et al (2016) Ultrasonography for hand and wrist conditions. J Am Acad Orthop Surg 24:544–554CrossRefGoogle Scholar
  46. 46.
    Pratt R, Hoy G, Bass Franzcr C (2004) Extensor carpi ulnaris subluxation or dislocation? Ultrasound measurement of tendon excursion and normal values. Hand Surg 9(2):137–143CrossRefGoogle Scholar
  47. 47.
    Lee K, Ablove R, Singh S et al (2009) Ultrasound imaging of normal displacement of the extensor carpi ulnaris tendon within the ulnar groove in 12 forearm-wrist positions. AJR 193(3):651–655CrossRefGoogle Scholar
  48. 48.
    Lourie G, Hamby Z, Raasch W et al (2011) Annular flexor pulley injuries in professional baseball pitchers: a case series. Am J Sports Med 39(2):421–424CrossRefGoogle Scholar
  49. 49.
    Klauser A, Frauscher F, Bodner G, Halpern EJ, Schocke MF, Springer P, Gabl M, Judmaier W, zur Nedden D (2002) Finger pulley injuries in extreme rock climbers: depiction with dynamic US. Radiology 222(3):755–761CrossRefGoogle Scholar
  50. 50.
    Martinoli C, Bianchi S, Cotten A (2005) Imaging of rock climbing injuries. Semin Musculoskelet Radiol 9(4):334–345CrossRefGoogle Scholar
  51. 51.
    Bodner G, Rudish A, Gabl M et al (1999) Diagnosis of digital flexor tendon annular pulley disruption: comparison of high frequency ultrasound and MRI. Ultraschall Med 20:131–136CrossRefGoogle Scholar
  52. 52.
    Gitto S, Messina C, Mauri G, Aliprandi A, Sardanelli F, Sconfienza LM (2017) Dynamic high-resolution ultrasound of intrinsic and extrinsic ligaments of the wrist: how to make it simple. Eur J Rad 87:20–35CrossRefGoogle Scholar
  53. 53.
    Finlay K, Lee R, Friedman L (2004) Ultrasound of intrinsic wrist ligament and triangular fibrocartilage injuries. Skelet Rad 33:85–90CrossRefGoogle Scholar
  54. 54.
    Taljanovic M, Goldberg M, Sheppard J, Rogers LF (2011) US of the intrinsic and extrinsic wrist ligaments and triangular fibrocartilage complex- normal anatomy and imaging technique. Radiographics 31(1):e44CrossRefGoogle Scholar
  55. 55.
    Noszian I, Dinkhauser L, Orthner E et al (1995) Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US. Radiology 194(1):61–63CrossRefGoogle Scholar
  56. 56.
    Murphey S, Hashimoto B, Buckmiller J et al (1997) Ultrasonographic stress testing of ulnar collateral ligament injuries of the thumb. J Ultrasound Med 16:201–207CrossRefGoogle Scholar
  57. 57.
    Hergan K, Mittler C, Oser W (1995) Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US and MR imaging. Radiology 194(1):65–71CrossRefGoogle Scholar
  58. 58.
    O'Callaghan B, Kohut G, Hoogewoud H (1994) Gamekeeper thumb: identification of the Stener lesion with US. Radiology 192(2):477–480CrossRefGoogle Scholar
  59. 59.
    Melville D, Jacobson J, Haase S et al (2013) Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited. Skelet Radiol 42(5):667–673CrossRefGoogle Scholar
  60. 60.
    Ebrahim F, De Maeseneer, Jager T et al (2006) US diagnosis of UCL tears of the thumb and Stener lesions: technique, pattern-based approach, and differential diagnosis. Radiographics 26:1007–1020CrossRefGoogle Scholar
  61. 61.
    Cockenpot E, Lefebvre G, Demondion X, Chantelot C, Cotten A (2016) Imaging of sports-related hand and wrist injuries. Radiology 279(3):674–692CrossRefGoogle Scholar
  62. 62.
    Schroeder N, Goldfarb C (2015) Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med 34(1):117–126CrossRefGoogle Scholar
  63. 63.
    Martinoli C, Perez M, Bignotti B, Airaldi S, Molfetta L, Klauser A, Demondion X, Cotten A, Tagliafico A (2013) Imaging finger joint instability with ultrasound. Semin Musculoskelet Radiol 17(5):466–476CrossRefGoogle Scholar
  64. 64.
    Prucz R, Friedrich J (2015) Finger joint injuries. Clin Sports Med 34(1):99–11CrossRefGoogle Scholar
  65. 65.
    Jacobson J, Powell A, Craig J et al (1998) Wooden foreign bodies in soft tissue: detection at US. Radiology 206:45–48CrossRefGoogle Scholar
  66. 66.
    Rubin J, Adler R, Bude R et al (1991) Clean and dirty shadowing on US: a reappraisal. Radiology 181(1):231–236CrossRefGoogle Scholar
  67. 67.
    Bianchi S, Della Santa D, Glauser T et al (2008) Sonography of masses of the wrist and hand. AJR 191:1767–1775CrossRefGoogle Scholar
  68. 68.
    Tayal V, Hasan N, Norton H et al (2006) The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med 13:384–388CrossRefGoogle Scholar
  69. 69.
    Jebson P (1998) Infections of the fingertip: paronychias and felons. Hand Clin 14(4):547–555PubMedGoogle Scholar
  70. 70.
    Marvel B, Budhram G (2015) Bedside ultrasound in the diagnosis of complex hand infections: a case series. J Emerg Med 48(1):63–68CrossRefGoogle Scholar
  71. 71.
    Pang H, Teoh L, Yam A et al (2007) Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg Am 89:1742–1748CrossRefGoogle Scholar
  72. 72.
    Chau C, Griffith J (2005) Musculoskeletal infections: ultrasound appearances. Clin Radiol 60(2):149–159CrossRefGoogle Scholar
  73. 73.
    Padrez K, Bress J, Johnson B, Nagdev A (2015) Bedside ultrasound identification of infectious flexor tenosynovitis in the emergency department. West J Emerg Med 16(2):260–262CrossRefGoogle Scholar
  74. 74.
    Cardinal E, Bureau N, Aubin B et al (2001) Role of ultrasound in musculoskeletal infections. Radiol Clin N Am 39(2):191–201CrossRefGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2018

Authors and Affiliations

  1. 1.Department of RadiologyHenry Ford HospitalDetroitUSA
  2. 2.Department of RadiologyUniversity HospitalClevelandUSA

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