대 한 방 사 선 의 학 회 지 1992 ; 28 (2) : 27 5~28 0 Journal of Korean Radiological Society , March , 1992

Sonographic Characterization of Tenosynovitis

Gwy Suk Seo, M.D. , Hyo Keun Lim, M.D. , In Jae Lee, M.D , Kil Woo Lee, M.D. , Sang Hoon Bae, M.D. , Kyung Hwan Lee, M.D.

D epartment of DiagnOstic RadioJogy, CoJJege o[ Medicine. HaJJym University

- Abstract-

Tenosynovitis of the extremities is not uncommon but its diagnosis is not easy owing to its non-specific clinical

manifestation. Thus it was beyond the field of imaging diagnosis so fa r. Recently the development of high resolu-

tion ultrasonogram has aided preoperative imaging diagnosis of tenosynovitis. The authors performed a retrospec-

tive review of 27 patients who had ultrasonography due to tendon pathology(including 18 tenosynovites) by obseπing

sonographic findings and evaluating the diagnostic value of each finding. The overall diagnostic accuracy was 81.1 %

and common sonographic findings were focal swelling of the tendon. well-defined margin of the lesion. preserved

fibrillar pattern. echo change of the lesion site and f1uid collection . Above al l. f1uid collection was the only

statistically significant criterion for diagnosis of tenosynovitis(p

Journal of Korean Radi이 ogical Society 1992 ; 28 (2) : 275~28D

three had tendon rupture and one had a s이id tumor.

Of all , twelve cases(six tenosynovites and six others)

were confirmed by operation and the others were

diagnosed on a clinical basis including labüratory fin-

dings and aspiration cytology. The sonographic

equipment we used were SSD-630(Aloka , Tokyo ,

Japan) and UM-4(ATL , Bothell , USA) with a 5.0 or

7 .5 MHz linear probe designed for small body part in-

vestigations.

We observed ultrasonographic findings with em-

phasis on the change of tendon size , outer margin of

the lesion , fibrillar pattern ofthe tendon at lesion site ,

echo texture of the lesion , and presence of calcificai-

tion or focal fluid collection. And then we evaluated

the significance of individual sonographic feature in

a statistical method using the Chi-square test with

Yates correction

RESULT

The commonest location of tenosynovitis was the

flexor or extensor tendon of the hand and wrist follow-

ed by the Achilles tendon , peroneus tendon , and the

quadriceps tendon in decreasing order of frequen-

cy(Table 1).

The clinical manifestations are listed in Table 2.

Focal swelling and pain are the major complaints and

Fig. 1. A transverse sonogram of the thumb shows swollen tendon and anechoic f1uid collection surrounding the tendon(arrow).

Fig. 2. The fibrillar pattern of the Achilles tendon is preserved(arrow) even in the inflammed area(arrow).

as many as seven patients were presented with overt mass. History of trauma was noted in four patients.

The ultrasonographic findings were as follows :

Table 1. Location of the Lesion in Tenosynovitis Group focal swelling of the tendon (Fig. 1) was found in 15

Location

Finger , Hand Achilles Peroneus Quadriceps Popliteal fossa

Number (%)

11 (6 1.1) 3 (1 6.7) 2 (1.1) 1 (5.6) 1 (5.6)

cases , the margin of the tendon was well defined in

11 cases , but ill-defined in seven cases. the fibrillar

pattern of the tendon was preserved(Fig. 2) in 13

cases, partially disrupted in four cases and complete-

ly lost in one case(In this case, sonographic diagnosis

was erroneous) . Ten lesions showed different echo

texture from the remaining portion of the tendon ,

Table 2. Clinical Manifestations in Tenosynovitis Group six of them were hypoechoic and four were mixed

Manifestation

Focal swelling Pain Mass Limitation of motion Trauma association

Number (%)

9 (50 .0) 7 (38 .9) 7 (38.9) 1 (5 .6) 4 (5.6)

echogenic. Of nine cases with fluid collection(Fig. 3) ,

regional focal fluid collection in three cases and dif-

fuse collection paralleling the tendon course in six

was found. Totally three cases had calcification(Fig.

4 ), one of which proved to be tuberculosis and the

others were diagnosed as non-tuberculous tenosy-

novitis(Table 3).

- 276-

Fig. 3. Normal sized extensor tendons of the wrist are surrounded by l1uid(arrows) within common synovial sheath.

The sonographic findings of non-tenosynovitis

cases are listed on table 4

The overall diagnostic accuracy of this series was

81 . 1 % and the only single sonographic finding- l1uid

collection-was statistically significant for the

diagnosis of tenosynovitis.(pO .25) And also no combination

of sonographic finding was significan t.

Table 3. Sonographic Findings of Tenosynovitis Group

Gwy Suk Seo , et al : Sonographic Characterization of Tenosynovitis

Fig. 4. A longitudinal sonogram of the Achilles tendon shows hypoechoic area with multiple calcific dots(ar-rowheads).

DISCUSSION

Many tendon abnormalities go undetected or go

neglected without call for medical advice . However ,

tendons are a very common site of injury. Inflam-

matory conditions are the second most common

category of tendon abnormality. Tendons are

Patient Fibrillar* * Fluid Swelling Margin ‘ Echo*** Calcification

+ + 2

3

4

5

6

7

8

9

m U

u m M

mu

m n

mω

+

+

+

+ + +

+ +

+ +

+

+

+

+

+

+

+ + +

+

+

+ +

+

* ( +); well defined margin of tendon * *( + ); preserved fibrillar pattern of tendon * * * ( + ); change of echo texture of lesion

+ +

+

+

+ +

+

+ +

+

+ +

+ +

+ +

+ +

+ + + +

+ +

+ + + +

+ +

+

+ + +

+

낌

Journal of Korean Radi이 ogical Society 1992 ; 28 (2) : 275~280

Table 4. Sonographic Findings of Non-Tenosynovitis Group

Calcification Fluid Echo*** Fibrillar ‘ • Margin* Swelling Patient

+ + +

+

+ + +

+

F +

+

l

2

3

4

5

6

7

8

9

+ +

+

+

+

+ +

+

+ + + +

*( +) ; well defined margin of tendon * *( +); preserved fibrillar pattern of tendon

* * • (+); change of echo texture of lesion

+

Table 5. US findings vs their Significance in Tenosynovitis

P valve specificity (e)

sensitivity (e)

False

(-) False

( + )

True (-)

True (+)

US finding

>0 .50

>0 .50

>0.75

>0.25

0 .50

33.3

22.2

33.3

44.4 100.0

100.0

83.3

6 1.1 72.2

55.6

50.0

16.7

3

7

5

8

9

샌

6

7

6

5

0

0

3

2

3

4

9

9

mω n

퍼 m

9

3

Swelling Margin*

Fibrillar* * Echo***

Fluid

Calcification

*( +) ; well defined margin of tendon * ‘ ( +); preserved fibrillar pattern of tendon

* * *( +) ; change of echo texture of lesion

quickly into adjacent tendinous structures especial-

ly in hands where common synoviaJ sheath envelops

the deep and superficiaJ flexor tendons at the finger

leveI(6). Tenosynovitis is not only the result ofminor

or vigorous trauma. calcific deposit or infection(7.8).

but is associated with other arthritides such as

rheumatoid arthritis or tuberculosis(8). The concept

of a special form-nodular tenosynovitis is stilI under

controversy. Some regard it as a giant ceIJ tumor of

the tendon sheath and others insist it is a synovial

inflammation(6.7) .

Ultrasonographic examination has been

established method for tendon pathology but its main

application was for tumorous conditions and

traumatic ruture(l -5) . There have been only a smaIJ

number of articIes on tenosynovitis. Jeffrey. J r.

reviewed surgicaIJy confirmed acute tenosynovitis

and the sonographic finding was hypoechoic area sur-

rounding the involved tendon(ll) and a case report

enveloped by a double layered synovial sheath when

they pass through an osseofibrous tunnel such as in

hands and feet(6) . So tendinous inflammation easily

develops into tenosynovitis or vice versa. It spreads

an

Fig. 5. A well-demarcated mass from the flexor tendon of the ha nd has homogeneous echogenicity and calcific foci It was misdiagnosed as benign tumor sonographically.

- 278-

Gwy Suk Seo, et al : Sonographic Characterization of Tenosynovitis

by Stephenson shows peritendinous f1 uid with nor-

mal tendons( 12)_ In our series , the main findings were

focal swelling of the tendon with preservation of a

fibrillar pattern , well-defined margin and f1uid collec-

tion. Focal swelling and preserved fibrillar pattern is

of high sensitivity but quite non-specific. In contrast ,

f1uid collection is of statistical significance in diagnos-

ing tenosynovitis

In seven cases which had initial manifestation of

palpable mass , the suspected mass proved to be

swelling of the tendon in four cases , f1uid collection

without tendon change in one case , focal swelling of

the tendon in one cases and actual mass discovery

sonographicallY in one case. The last case was

misdiagnosed preoperatively(Fig. 5) . In another case

with complete disruption of the fibrillar pattern ,

tenosynovitis could not be suggested. There were two

cases whose ultrasonographic dignosis was

tenosynovitis , but were confirmed to be fibroma and

ganglion at operation. Likewise , focal swelling

without f1uid colleciton of the tendon remains a

diagnostic pitfall , which says again that f1uid colle-

tion is criterion of high specificity but low sensitivity

In conc1usion , ultrasonography is useful in

diagnosing tenosynovitis and the major specific

sonographic finding is f1uid collection. But differen-

tiation between nodular tenosynovitis and benign

tumor by ultrasonography is still problematic.

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Journal of Korean Rad i이 og ica l Society 1992 ; 28 (2) : 275 "'-'280