Standard Scans Wrist

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Pediatric hand & elbow

Johannes Roth, MD PhD FRCPC RhMSUS

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Positioning of the patient:

1)Sitting position

Positioning of the hand on top of the thigh or on an examining table

Dynamic examination with active flexion/ extension of the fingers

2) vary all positions especially for Doppler – dynamic exam !!!

Wrist - Sonography

(4)

Standard Scans Wrist

1. Volar transverse scan 2. Volar longitudinal scan

3. Dorsal transverse scan (radial) 4. Dorsal transverse scan (ulnar) 5. Dorsal longitudinal scan (radial) 6. Dorsal longitudinal scan (median) 7. Dorsal longitudinal scan (ulnar)

Rad Lunate Capitate Metc

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Ossification wrist

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9 year old

4 year old

Wrist long

3 year old

Radius Lunate Capitate Metcar

(7)

3 year old boy

5 year old boy

Radius Lunate Capitate Metc

(8)

Wrist transverse dorsal Dorsal

slightly moredistal

Radius Ulna

(9)

wrist transverse volar

Pisiforme Scaphoid

Pisiforme Scaphoid 5 year old

15 year old

(10)

Ossification Fingers

(11)

Epiphysis Formation Fingers

2 y old girl

(12)

Pseudoepiphysis Formation

3y6m boy

(13)

Pseudoepiphysis

mature phase with indentation

(14)

MCP dorsal 10 y old

Metacarp Phalanx

longitudinal transverse

(15)

MCP volar

Cart

Metacarp Phalanx

Volar Plate

Tendons

Pulley 0.2 mm Pulley

Metacarp

Tendons Cartilage 10 year old

(16)

Synovitis Wrist

Radius Lunate Capitate Metc

(17)

Synovitis Wrist

Lunate / Triquetrum Capitate/Hamate

(18)

Synovitis Wrist

Lunate / Triquetrum Capitate/Hamate

(19)

Tenosynovitis Wrist

(20)

Ganglion Cyst

(21)

Carpal tunnel children

Tenosynovitis

Accessory Muscles MPS

(22)

PIP long trans

15 year old with flexion contractures / decreased range of motion

A3 pulley

(23)

Carpal Tunnel Symptoms

MN

(24)

Mucopolysaccharidosis Type I attenuated phenotype

Lateral collateral Ligament knee

(25)

Radius Lunate

Right

Left

(26)

accessory muscle protruding into the carpal tunnel

(27)

Synovitis and Subluxation MCP

(28)

Synovitis ?

(29)

Synovitis and Tenosynovitis Fingers

(30)

Pathology ?

(31)

Position Erosions

Karmazyn et al Ped Radiol 2007

(32)

Ligaments

(33)

The patient with painful, thickened PIP joints

(34)

Pulleys

Most common problem - Trigger Finger Differential Diagnosis:

Congenital

Tenosynovitis MPS

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The Elbow Joint

Anterior Posterior

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Elbow

This and all other radiologic and anatomic images taken from Ogden-JA Development of the Human Skeleton

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Distal Humerus

4 secondary ossification centers with variation in appearance 1) Capitellar center: six weeks to eleven months (average five

months in boys, one to seven months (average four months) in girls

2) Medial epicondylar center: five to seven years in boys and three to six years in girls

3) Trochlear center: eight to ten years in boys and seven to nine years in girls

4) Lateral epicondyle: average twelve years in boys and eleven in girls.

(40)

Distal Humerus

Neonate 9 Months

(41)

Distal Humerus

9 years

Capitulum Humeri

Medial Epicondyle

(42)

Proximal Forearm / Elbow

(43)

Humeroradial 10 year old

(44)

Doppler Signal

Doppler signal may be normal in developing joints

J. Roth, MD

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Humeroradial 3 year old

(46)

Humero-ulnar 3 year old

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Humero-ulnar 10 year old

(48)

Elbow posterior long 3 year old

(49)

cartilage outline posterior

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Elbow posterior long 10 year old

(51)

Lateral ligaments

Ann

LateralLig

UCL

AL

(52)

Lateral longitudinal 10 year old

1. Lateral epicondyle 2. Extensor tendon origin 3. Radial head

1 3

Humerus Radius

(53)

Lateral longitudinal 3 year old

(54)

Medial Collateral Ligament Complex

Anterior UCL Trans

UCL post

UCL

(55)

Medial longitudinal 10 years old

(56)

Medial elbow 3 year old

(57)

Medial epicondyle Doppler

(58)

Synovitis

(59)

(60)

Ulnar Nerve Subluxation

• Ulnar nerve instability is common in pediatric patients

• Not always associated with morphoplogical changes of the nerve

• more common in younger children / pre adolescents (up to 22 %)

• Clinical features include posteromedial radiating elbow pain with

paresthesia in distribution of ulnar nerve but it is often asymptomatic as well

• Enlargement and decreased echogenicity acutely

Medial epicondyle

Erez O, et al. J Pediatr Orthop. 2012;32(6):641-6.

Finlay K, et al. Skeletal Radiol 2004;33:63-79.

Subluxed nerve

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Thank You !

(62)

Standard Scans Elbow – medial longitudinal

medial epicondyle

ulna

common flexor tendon

aUCL

Common flexor tendon

Humerus

Ulna

(63)

Standard Scans Elbow – lateral longitudinal

Common ext tendon

Lateral epicondyle radial head

supinator muscle

Common extensor tendon

RCL

Humerus Radius AL

Common extensor tendon and muscles

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