hi I'm Dr Muhammad bardy I'm a rumatologist and today I'll be demonstrating for you doing a hand scan assessing for inflammatory changes such as citis and tenosinovitis in the hand what's really important in Rheumatology scanning is that we actually apply a gel layer uh and when we're scanning we want to try to maintain that gel layer throughout our scan so that you're not compressing the structures so that if you don't olude capillaries when you're looking at these small flow vascular changes when looking for inflammation so as we look through every region mCP pip dip joint we want to get them in longitudinal and transverse fuse and then when we look at the volar aspect of the hand same thing as we go through each of those regions so I'll take you through the dorsal aspect of the hand we'll turn things over and then look through the vlar aspect so starting from the top you can see here as I come into view I have my focal point set to the region of Interest I have a gel a present at the top you can see the Bony cortex we get to the metacarpal head and at the metacarpal head you'll see an anaco line on top of it that's actually the cartilage on the surface of the bone at the proximal failen you'll see that there's some cartilage there as well and then in that v-shaped space that's actually where the synovium is now if somebody has a joint of fusion that would actually lift up and if they start to have sinovitis that area will become more and more hypo aoic and it could spread over the proximal aspect of the joint as well so we can look at the degree of sinovial thickening and enhan and changes more superficial to that area you'll see this band of tissue kind of running through the top that's actually the extensor tendon we can see that through the top and there can be inflammation there in ptic arthritis people can get paron inflammation it has been reported in other conditions but usually be associated with psoriatic arthritis so while we're here so this is your longitudinal views we want to put our Doppler on as well so usually we use power doppler historically it had more sensitivity compared to color Doppler but on most modern equipment you can use either Doppler form you do want to be in a slow flow setting or if you can adjust your prf settings we want to be between 500 to 1,000 khz and you know you'll see that we're basically trying to find detect really slow flow changes through the cium we do want our gain settings adjusted so that there's a little bit of background artifact but not so much where it's difficult to see your image so we'll scale that accordingly we're just trying to really see as much sensitivity as we can if there's any abnormal or increased flow you want your Doppler box from the top of the screen down in case there's any other superficial vessels in case they cause an artifact and you do want to scan around the joint so we were going to sweep around the joint along the radial aspect we're looking for erosions in the Bony Contours we're looking for sinovial thickening Doppler signal and you want to move along the allner aspect of the joint and if you think of the joint as a 3D structure you want to come at it from an angle you want to see if there's erosions this is kind of think of it as coming at the 10:00 position and then as you sweep around coming around to the radial aspect from like the 2:00 position so you want to see that and assess the joint tissues and then from here I'll go back to my B mode if I look at things in transverse view uh as I go proximal to the Joint uh space I'll see here's the the bright white line that's the Bony cortex of the metacarpal um and then above that superficial you can use your anosy tropy you can see there's an area that becomes hypoc coic that's the extensor tendon and there's these little bands that come along the sides a little bit harder to see here but you can kind of make them out those are the Sagal bands they connect the extensor tendon and anchor it to the metacarpal head so as we start to move distally now you'll see the bone bone bone and then I start to lose that there's a region where I pass through the joint space here I'm in the joint space and then I'm now onto the proximal aspect of the fail lanks so you want to assess this whole area you do also want to look at this area with your Doppler on as well and again keeping very light pressure and you want to look to see is there any sort of changes signal around the extensor tendon is there any sort of signal in the sinovial space and as you come through there are digital arteries you may pick up signal from those as well don't confuse that for sinovitis so with that said we're going to keep moving on we're going to look at the uh pip joint here as well so keeping that light contact we can see the extensor tendon here that more hypo coic line through here as I come down we can see the cortex of the bone as we follow this down we're now getting to the PIP joint and you may want to increase your focal point to come up a little bit higher so we can focus on the tendon there's the extensor tendon it fans out the central slip will come in insert onto the proximal aspect of the middle failen you can see the joint space here as well um so if there was joint space narrowing bony formation osteophytes you want to sweep allner to radial to get a sense of the Bony Contours and then you do also want to rotate your probe 90° as you look at the bone cortex here coming down seeing that space seeing if there's any sort of irregularity erosions and again as you pass through the joint space there and just like I had previously shown you you do want to put your Doppler box on and again looking here is there any sort of paron inflammation is there any sort of sinovitis that you can detect as you go through that space and not only do you want to see that in your trans views but in your longitudinal views as well so you want to be able to visualize that also as we continue on from here going into the dip joint it's the same principles that apply we can follow this down really nicely we get down here I've centered the dip joint here you can see distally this is the nail plate and then you get see the nail bed uh you get this Tri laminer appearance you can still make it out on this so in sertic arthritis there can be thickening in the nail plate in the nail bed you can see the uh The Matrix of the nail as well and you can see where the extensor tendon comes and attaches onto the dip joint on the proximal aspect of the distal failen here and again similarly you want to put on your power doppler you want to sweep all ner to radial looking at that space and with that um uh you also want to turn your probe 90° looking at that and as you start to move distally looking at the bony cortex is passing through the joint space um to look for any changes there as well with that that would conclude the dorsal scan of the hand we're going to turn the hand over now and when you're scanning the Palmer aspect of the hand I'll use the third digit as our example when you're scanning the second digit sometimes you do have to abduct the finger to keep the tendon in a long nice Long View but we'll use a third digit here so we're going to come down here and I'm going to drop my focal point down so we can see the flexor tendon in view um so you can do Dynamic testing to actually see the tendon moving okay and there's a lot of things you can appreciate here so we want to look for specifically in Rheumatology is there ositis is there inflammation or swelling there's be mode changes that you'll see like if there's fluid or anaco changes or swelling around it you can look for that sometimes as you do your Dam testing if somebody presents with trigger finger they could have a flexor tendon nodule and you could actually look for nodularity or if there's a region where that's it's thicker or bigger I don't see that in this case and one thing I'll draw your attention to there's a little black hypo aoic band above the tendon just above the middle of the joint space and that's actually the A1 pulley that's a tissue that wraps around the tendon that can become thickened and it can be a source of trigger finger as well so you can check that dynamically deeper to that you'll see the metacarpal head is the the Bony Contours that bright white line You'll see the Highland cartilage as well you'll see the joint space there is a sinovial recess here as as well so if somebody has sinovitis you can see thickening or fullness you can see this both in longitudinal plane if we rotate our probe 90° we can also see the tendons here so you can tilt your the probe to use the anosy tropy to highlight for you the tendons as well as I come down a bit distally you can see the metacarpal head here as well and one of the things that you'll be able to appreciate is you can see the A1 pulley in these transverse views so as I come down you'll see this little black Halo that kind of forms a around the tendon here and I'm going to bring my focal point up and you this little Halo that goes around it that's actually where the A1 pulley is um so that can become thicker as well and you can measure that if you're interested and as you move down so I'm on you can see the metacarpal head here I move through the joint space and then the proximal fail length is there if you have your Doppler on you could be looking for any sort of Doppler signal in the tendon for assessing inflammatory changes in the tendon and we can bring our focal point to the the level of the tendon here and if you're finding that you're getting too much background artifact you can reduce your Doppler gain you can come down so that you're just at that threshold where there's some signal but not too much and then you can um you can assess that area of interest you want to see that in longitudinal and in uh transverse views and as You Follow the tendon you want to visualize the tendon come all the way down there are A2 A3 and A4 pulley I will not uh get into the details of those for the purpose of this scan and um when you come all the way down here you can see the PIP joint on the vlar aspect here we can see the distal part of the middle failinks and the proximal part of the middle failing here there's the vlar plate uh you can see the Highland cartilage on the bone here we can actually move the tendon to separate where the tissue planes are for the vlar plate compared to the tendon as well if you turn your probe 90° here we can also see the cartilage at the bone here you can use your anosy tropy to show you the margins of the tendon and how that's different from the V plate just beneath it and these views here you can see if there's joint space narrowing osteophytes if there's an infusion you can actually see a little bit of the sinovial recess here if there was swelling or diffusion or sinovitis it would distend this area here so very helpful to to be able to look at these spaces sometimes you'll see more pathology on the dorso side sometimes it's more on the vlar side you can continue to follow that tendon come more distally and then you'll be you can now in this view see the PIP and dip joints we can see the ex uh the flexor tendons coming all the way down and you can see the joint space this little black space that you see proximal to the dip joint that's where the sinovial recess is if there was citis that would enlarge you could look for Doppler signal there too um just like I'd shown you at the other joint spaces so you want to see longitudinal and you would want to see uh transer View and with that that would conclude scanning of the digits
