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  • 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

    m ω

    +

    +

    +

    + + +

    + +

    + +

    +

    +

    +

    +

    +

    +

    + + +

    +

    +

    + +

    +

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

    + +

    +

    +

    + +

    +

    + +

    +

    + +

    + +

    + +

    + +

    + + + +

    + +

    + + + +

    + +

    +

    + + +

    +

  • 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

    6

    7

    6

    5

    0

    0

    3

    2

    3

    4

    9

    9

    m ω 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-