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Foreign bodies in soft tissues are commonly encountered in daily orthopaedic practice. While most of the metals and glass foreign bodies can be detected by plain radiograph, organic substances such as wood and vegetative materials are radiolucent. Unfortunately, these radiolucent foreign bodies are usually more prone to cause an inflammatory reaction and infection. The detection can be even more difficult in cases of multiple foreign bodies and in penetrating injuries with small innocuous skin wounds. Ultrasonography is a sensitive and reliable investigation for detection of foreign bodies in soft tissue. We present a case of penetration injury to thumb with residual radiolucent foreign bodies and demonstrate the proper role of ultrasonography in the management of foreign bodies in soft tissues.

A retrospective analysis of 227 patients undergoing ultrasonography (US) of the hand/wrist over a three-year period in a district general hospital trust was performed. The usefulness in each case was assessed by two independent reviewers using a qualitative rating system, as (A) Useful: determines management, (B) Useful: contributory, (C) Not useful: not misleading, or (D) Not useful: misleading/potentially harmful. US was useful in 74.8% of cases but misleading/potentially harmful in 13.1%. Misleading rates exceeding 10% in sub-categories including tendinopathy, carpal tunnel syndrome, foreign body and lumps, where US findings may influence the decision to operate or not, are particularly worrying. There were a number of cases where US led to unnecessary operations or suggested operating on the wrong structures, and also cases where US findings wrongly suggested that surgery was unnecessary. Various recommendations aimed to improve the usefulness of US in the Hand and Wrist, including mandatory/formal musculoskeletal US training, are made.

We have retrospectively reviewed the clinical, preoperative ultrasonographic, and operative findings of eight patients who had tardy ulnar nerve palsy caused by a cubitus varus deformity. The mean varus angle on the affected side was 23°. With preoperative ultrasonography, the anterior dislocation of the ulnar nerve from the medial epicondyle was detected in dynamic scanning of short-axis images, and long-axis images revealed nerve compression and kinking in the proximal border of the flexor carpi ulnaris. Operative findings revealed compression of the ulnar nerve by a fibrous band, which was released in all cases. The cause of the tardy ulnar nerve palsy in this series of patients was constriction by a fibrous band and kinking in the proximal border of the flexor carpi ulnaris due to ulnar nerve dislocation from compression resulting from the forward movement of the medial head of the triceps brachii muscle.

Carpal tunnel syndrome caused by a ganglion is a rare condition. We report a case which presented with a rapidly progressive onset of symptoms and subsequent thenar palsy.

Background: To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate.

Methods: The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles).

Results: Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion.

Conclusions: The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.

Tibial stress fractures (SFs) are a common orthopedic problem during military basic training. Bone scan is considered the gold standard for diagnosing this condition. Several case reports have described sonographic features of stress fractures. This is a prospective, double-blind study to compare diagnostic ultrasound (US) examination with isotope bone scan in diagnosing SF. Thirty-one soldiers who were referred to the nuclear medicine service for a bone scan to rule out tibial SF participated in this study. The SF lesions of the lower extremities were classified according to the classification criteria introduced by Zwas et al.²⁰ US examination was performed on the same day. Areas of cortical thickening and other pathologies like bone surface irregularity and bone discontinuity were recorded. Each examination was graded as either normal or suggestive of representing a SF. Thirty of 62 tibiae were diagnosed as having SF according to bone scan, whereas US examination suggested SF in 35 tibiae. US examination was positive in 20 of 30 tibiae with SF (67% sensitivity, 53% specificity). Although US correctly diagnosed SF in 20 tibiae, bone scan remains the chosen imaging modality to detect SF in soldiers. US was not found to be a reliable modality to diagnose SF.

Ultrasonography is frequently used to measure the rectus femoris muscle cross-section area, and has been suggested to associate with poor health condition. However, no validation studies have been performed to compare rectus femoris muscle ultrasonography (RFMS) with anatomical planimetry when measuring the muscle cross-sectional area (CSA). This validation study compared the two methods of CSA measurement of unfixed (frozen) and fixed (unfrozen) rectus femoris muscle specimens obtained from elderly human cadavers. Agreement between tests was studied by Bland–Altman analysis. We found a significant difference between planimetry and RFMS of unfixed (frozen) muscle specimens (mean difference, -0.389 cm²; 95% CI, -0.144 to -0.634), p = 0.022. No significant difference was observed between the two methods when measuring fixed (unfrozen) muscle specimens (mean difference, 0.032 cm², 95% CI, -0.007 to -0.070), p = 0.107. In fixed specimens, the 95% limit of agreement between the two methods ranged between 0.12 cm² and -0.06 cm² (<10% deviation); while in unfixed muscle specimens, the range was between 0.28 cm² and -1.06 cm² (~50% deviation). In light of the similar results obtained in fixed specimens, ultrasound is a safe and accurate method of rectus femoris muscle size assessment. In clinical practice, RFMS may be used to detect a decrease in rectus femoris muscle mass, typically associated with malnutrition of the elderly, and may therefore be a simple and practical tool for the screening of malnutrition.

Introduction: Posterior tarsal tunnel syndrome (PostTTS) refers to compression of the tibial nerve (TN) within this tunnel. PostTTS is most commonly secondary to entrapment with subsequent inflammation. As it is true with other entrapment-type neuropathies, corticosteroids could provide therapeutic relief. To the authors' knowledge, the feasibility of such injections using ultrasound guidance has not been described in the literature. We hypothesize that one can inject the TN perineural space immediately proximal to the posterior tarsal tunnel utilizing ultrasonography US-guidance. Methods: This research was a pilot study using four cadaveric models. US was utilized to image the proximal posterior tarsal tunnel. Perineural injections of methylene blue were performed with subsequent dissection. Injections were designated as accurate (referring to nerve staining) and precise (referring to dye localization). Results: One cadaver was precluded due to pronounced musculoskeletal abnormality. 5-of-6 (83%) injections were accurate and 6-of-6 (100%) precise. Conclusion: Initial attempt was inaccurate and precise, while later injections were both accurate and precise. The most apparent source of error was from one cadaver's pronounced musculoskeletal deformity, which precluded successful injections bilaterally. Of the three cadavers unaffected by musculoskeletal deformity, accuracy was 5-of-6 (83%) and precision was 6-of-6 (100%). While surgery is the definitive treatment for refractory PostTTS, therapeutic effect of corticosteroid injections has not been evaluated in this patient population. Such injections could provide symptomatic relief and postpone surgical intervention. Small sample size not withstanding the results suggest that TN perineural injections are feasible under US-guidance. This study suggests that US-guidance can increase accuracy and precision and is a potential adjunct to the treatment. Future study will expand the initial data set and categorize consistent protocol. Subsequent translational research will then be sought to evaluate therapeutic efficacy in this patient population.

Purpose: Describe an alternative approach to perform ultrasound-guided injections into the cubital tunnel as a pilot study for cubital tunnel syndrome (CTS) treatment feasibility. Methods: The ulnar nerve was visualized bilaterally on four non-embalmed cadaveric models which were placed in a supine position. To image the cubital tunnel, the subject's elbow was examined in external rotation with the elbow angle at approximately 40° flexion (full elbow extension is considered 0°). The ultrasound transducer was placed transverse to the condylar groove along the medial epicondyle-olecranon axis and the ulnar nerve was identified. Methylene blue 0.35 mL was injected into the ulnar nerve perineural space under ultrasound guidance in a lateral-to-medial approach. Post-injection incisions were made to expose the underlying ulnar nerve and examine the injection sites. Injections were considered accurate if the ulnar nerve perineural space was dyed, and were considered precise if the injection was localized without damaging the ulnar collateral artery. Results: Dissection revealed that the ulnar nerves were covered with dye from the cubital tunnel inlet to outlet. 8-of-8 (100%) injections were accurate; 8-of-8 (100%) injections were precise. Conclusion: This pilot study shows that a lateral-to-medial approach to injecting the cubital tunnel under ultrasound guidance is accurate and precise. The clinical efficacy of such a procedure using corticosteroids should be examined through clinical trials and the results should be compared to other techniques used for treating CTS.

Purpose: To investigate whether the pennation angle (PA) in the abdominal muscles of individuals with spastic type cerebral palsy (STCP) has undergone any change when compared with those of typically developing (TD) individuals. To determine whether PA of abdominal muscles in individuals with STCP impacts differently on the force generating capacity, from those of TD peers. Materials & methods: Ultrasound images of the four abdominal muscles namely; rectus abdominis (RA), internal oblique (IO), external oblique (EO) and transversus abdominis (TrA), were obtained during the resting and active stages. ImageJ software package (version 2012) was used to measure the PA of the sonographic images. Sixty-three individuals with STCP and eighty-two typically developing (TD) individuals took part in the study. The participants were between the ages of 7 and 16 years. Results: The PA for three out of the four abdominal muscles was less than 3${}^{\circ }$ while the RA muscle in both groups showed a pennation angle of zero degrees during the resting and active stages. Conclusion: Excluding the rectus abdominis muscle, PA appeared to be altered in individuals with STCP when compared to their TD counterparts. The characterization of PA in abdominal muscles in both groups is, however, unclear. The PA as a muscle parameter may not be an important variable for differentiating the force generating capacity between individuals with STCP and their TD peers. Further investigation is required on MAP and the overall implication of each component on abdominal muscle function, especially in the maintenance of balance and posture.

Purpose: Pes anserinus bursitis is a commonly overlooked cause of medial knee pain. It is diagnosed clinically and involves tendons/bursa or both. Majority of studies fail to provide imaging evidence of tendon/bursal pathology in clinically diagnosed patients. This study documents the ultrasonographic findings associated with clinically diagnosed pes anserinus bursitis and correlates between clinical and positive ultrasonographic findings.

Methods: A cross-sectional study was done in outpatient department settings of physical medicine and rehabilitation department in participants with clinically diagnosed pes anserinus bursitis. Clinically evaluation was done by Physiatrist and ultrasonographic evaluation by a radiologist. Patient characteristics, clinical findings and ultrasonographic features were documented and studied.

Results: In the evaluated 67 knees, Pes anserinus tendonitis (53.73%) with statistical significance ($p=<0$.0001) was found on ultrasonography over bursitis (2.99%). Abnormal findings involving medial collateral ligament (38.81%), medial meniscus (26.87%), suprapatellar recess (47.76%), and other structures (17.91%) were also documented. Age, gender, body mass index, and duration had no effect on presence of positive ultrasonographic findings.

Conclusion: Ultrasonographic changes of tendonitis involving pes anserinus tendons correlate with clinically diagnosed pes anserinus bursitis. The ultrasonography also helps in identifying potential sources of pain other than pes anserinus tendon or bursa in such cases.

Purpose: To investigate morphological changes in the infrapatellar fat pad (IPFP) during active knee extension using ultrasonography.

Methods: IPFP deformity from 30^∘ knee flexion to full extension was recorded using ultrasonography. IPFP thickness and patellar tendon-tibial angle were evaluated on 26 healthy knees in the first session and nine knees in the second session. Intra-rater and inter-rate reliability were evaluated using coefficient of variation (CV) and intraclass correlation coefficient (ICC) of types (1, 3) and (2, 3), respectively. Absolute reliability was assessed using the standard error of measurement (SEM). Changes in the patellar tendon-tibial angle and IPFP thickness were analyzed using paired $t$-test.

Results: At each knee angle, ICC (1, 3) was $>0.90$ for the patellar tendon-tibial angle and IPFP thickness (CV $<8\%$). Compared to 30^∘ knee flexion, the patellar tendon-tibial angle increased significantly from 33.3^∘ to 38.9^∘ ($p<0.01$). The IPFP thickness significantly increased from 4.4mm to 5.3mm with active knee extension ($p<0.01$), without overlap of the 95% CI of SEM. For inter-rater reliability, ICC (2, 3) was $>0.7$ for each variable (CV $<11\%$).

Conclusions: Increased IPFP thickness during active knee extension indicates IPFP deformity in the anterior interval. Ultrasonography may help evaluate morphological changes and estimate IPFP scarring.

Background:This study was designed considering the existing controversies on the normal range of median nerve cross-sectional area (MNCSA) and its association with hand dominance.

Methods:In this cross-sectional descriptive study, the upper limbs of 100 healthy subjects (46 men and 54 women) were assessed bilaterally by sonography. MNCSA was measured at the level of the carpal tunnel inlet.

Results:Calculated MNCSA values were 9.29 mm² and 9.54 mm² for the right and left sides, respectively. No significant difference was observed between the right and left hands. No significant correlation was observed between hand dominance and MNCSA in right-handed or left-handed subjects.

Conclusion:Hand dominance does not significantly affect MNCSA at the wrist level, and thus does not affect the diagnosis of carpal tunnel syndrome.

Background: Plantar fasciitis, the impairments include pain, changed skin blood flow (SBF) and temperature, changed plantar fascia (PF) and flexor digitorum brevis (FDB) thickness, and affected foot function index. However, the association is still unknown.

Objective: The study aimed to determine the association among pain, SBF and temperature, PF and FDB thickness, and foot function index in individuals with plantar fasciitis.

Methods: Thirty-two individuals with unilateral plantar fasciitis were interviewed for demographic data and assessed for pain at the first step in the morning (Pain${}_m$), pain at rest (Pain${}_r$), and pain at 80 N/cm² pressure (Pain${}_{80}$) by visual analog scale (VAS), SBF, and skin temperature (ST) by laser dropper flowmetry (LDF), PF and FDB thickness by ultrasound imaging (USI), and foot function by foot functional index (FFI). The association was analyzed by the Spearman correlation coefficient.

Results: A significant correlation was found among Pain${}_m$ and Pain${}_r$, Pain${}_{80}$, SBF, PF, and FFI. Pain${}_r$ was correlated with SBF, and FFI. Pain${}_{80}$ was also correlated with FFI. SBF was correlated with ST and FFI.

Conclusions: The association among pain, PF thickness, and FFI was reported in individuals with plantar fasciitis, which can be meaningful relationship between clinical outcomes and ultrasonographic evidence.

Eighty cases of early DDH treated with Pavlik harness over a 10-year period in one centre was followed up for a minimum of 2 years with a mean of 6.5 years. Sixty-five percent of the patients presented to the clinic before the age of 4 weeks, and 10% after 12 weeks. Sixty percent presented clinically as dislocated reducible hip, 25% as dislocated non-reducible hip, and 15% as dislocatable hip. Static and dynamic ultrasonographic grading revealed 65% as pathological hip and 35% as normal. Clinical and ultrasonographic assessment revealed that 2 weeks after commencement of the Pavlik Harness treatment, 78% of the hips were reduced and this increased after 4 weeks, to 91.2%. The most significant factors affecting the outcome were the age at the start of treatment and the clinical type of hip. A 95% success reduction rate was achieved for those treated before the age of 8 weeks and only 50% for those after this age. Ninety-five percent of the dislocated reducible hips and 100% of the dislocatable hips were successfully reduced. Of the initial dislocated irreducible hips, only 50% were successfully reduced. At the final follow-up, the clinical and radiological assessment showed an overall success rate of 84%. Avascular necrosis was only found in 1 case (1.25%).

We report a case of bilateral carpal tunnel syndrome (CTS) with bilateral bifid median nerve (BMN) without a persistent median artery diagnosed by clinical examination, NCV and Ultrasonography. Bilateral BMN to produce bilateral CTS is extremely rare and is contrary to the popular classifications which state that BMN without persistent median artery or its anomalies will not produce CTS. Ultrasonogram is of additional help to identify such aberrations in the median nerve to prevent iatrogenic injuries during carpal tunnel decompression.

Background: Foreign bodies in the hand are common but easily and often missed in the initial evaluation of injury. Diagnosing retained foreign bodies is difficult due to radiolucent foreign bodies. Purpose of this study is to emphasize the need of consideration of foreign bodies in patients with chronic synovitis in hand.

Methods: Twenty-five patients who had retained foreign body in soft tissue of hand with chronic inflammation symptoms were included. Ultrasonography was conducted in all of the patients. Patient age, sex, localization of foreign body, duration of symptom, history of injury, follow up period, complication, and biopsy results were recorded and reviewed. Also, patients’ demographics and clinical results were retrospectively reviewed.

Results: Nine of the 25 patients diagnosed with a foreign body in the hand did not remember the initial presentation of injury. The average symptom duration (from injury to hospitalization) was 10.5 months (range 1–96 months). The middle finger and the proximal interphalangeal joint were the most common site of a retained foreign body (10 patients). All patients were diagnosed via ultrasonography and underwent surgery. Biopsy results showed mainly chronic inflammation, fibrosis, granuloma, and foreign bodies.

Conclusions: Patient with symptoms of cellulitis, osteomyelitis, and palpable mass in hand for over a month without a diagnosis should be suspected of retained FBs.

Background: The intracompartmental septum isolating the extensor pollicis brevis (EPB) has been reported to affect the patient’s response to nonsurgical treatment in de Quervain’s disease. A simple physical test called the modified staged Finkelstein test was developed to evaluate the septum; the result of this test was compared with those of the pre-existing physical test (EPB entrapment test) and ultrasonographic (US) examination of the septum.

Methods: We retrospectively analyzed 52 patients who underwent two clinical tests, including the modified staged Finkelstein test and the EPB entrapment test, and US examination for de Quervain’s disease. The correlation between the clinical test results and US findings was evaluated; sensitivity, specificity, and positive and negative predictive values were calculated.

Results: The proportion of wrists with a separate septum was 50% (26 patients) in the US examination. The sensitivity and specificity of the modified staged Finkelstein test were 88.5% and 73.1%, respectively; those of EPB entrapment test were 71.4% and 84.2%, respectively. The positive and negative predictive values of the modified staged Finkelstein test were 76.7% and 86.4%, respectively.

Conclusions: The modified staged Finkelstein test showed acceptable diagnostic values for the diagnosis of septum compared with pre-existing physical tests. Knowledge about the existence of septum could be helpful in treating patients and expecting prognosis.

We report two pediatric cases of radial nerve palsy caused by supracondylar fracture of the humerus requiring nerve exploration. The children had comparable conditions, palsy types (complete motor and partial sensory) and radiographic findings. The fracture in the first case was managed conservatively with closed reduction and percutaneous pinning but, while the patient eventually recovered from the partial sensory palsy, her motor palsy remained unchanged. In the second case, ultrasound assessment of the nerve prior to fixation indicated that surgical exploration was needed as it revealed tethering on the edge of the proximal fracture fragment. The nerve was released during an open reduction and the patient subsequently recovered from both sensory and motor palsies. Ultrasonography proved essential in the initial clinical assessment by determining how to proceed. We recommend primary nerve exploration when ultrasound findings show entrapment or tethering of the radial nerve.

Background: An open approach is the gold standard for trigger finger (TF) release. However, this may be associated with infection and scar tenderness. Percutaneous trigger release is an alternative, but this can sometimes result in incomplete release and digital nerve injury, even with ultrasound (US) guidance. Limited-open TF release is an intermediate technique that uses a specially designed knife via a 2–3 mm incision. The aim of this study is to compare the outcomes of blinded versus US-guided limited-open TF release using the Yasunaga knife (Medical U&A, Inc., Japan).

Methods: About 138 fingers in 111 patients underwent limited-open TF release using the Yasunaga knife. Green classification was used to grade the severity of TF. Thirty-one patients had grade 3 TF and 80 patients had grade 4 TF. The TF was released in a blinded fashion in 60 patients and using US guidance in 51 patients. Outcome measures included residual triggering, contracture of the proximal interphalangeal joint, visual analog scale (VAS) for assessment of pain, Quick Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patel and Moradia grading of patient satisfaction. Complications were also recorded.

Results: Six patients had residual triggering in the blinded group, whereas it resolved in all patients in the US-guided group. This difference was statistically significant (p = 0.03). Patients in both groups showed significant improvement in VAS and Quick DASH score postoperatively. There were no significant differences between the two groups for these two outcomes. Patient satisfaction was graded as excellent by 20 patients and good by 30 patients in the US-guided group compared to eight excellent and 45 good in the blinded group.

Conclusion: The incidence of residual triggering was lower and overall satisfaction higher in patients who underwent US-guided limited-open TF release using the Yasunaga knife.

Level of Evidence: Level III (Therapeutic)