Trapeziometacarpal osteoarthrosis: clinical results and sonographic evaluation of the interposed tissue after trapeziectomy and first metacarpal suspension by external minifixation at a minimal two-year follow-up.

Among the surgical options to treat trapeziometacarpal osteoarthrosis, trapeziectomy has been criticized as unable to prevent postoperative collapse of the thumb, causing painful scapho-metacarpal impingement. The implantation of an external minifixator between the first and the second metacarpals for sufficient time has been proposed to maintain the postoperative space created by the bone resection to allow the development of a resistant interposed fibrous tissue. Nineteen patients (16 women, 3 men, mean age 64.5 years) were evaluated at 3.3 years of follow-up after an unilateral trapeziectomy and first metacarpal suspension by external minifixation. Eighty-four percent of the patients were very satisfied with the operation. The mean DASH score was 27.7%, the pain 1.7/10 (Visual Analogue Scale), the opening angle of the first web 58.3° and the Kapandji opposition score 9.5/10. Sonography demonstrated the existence of a strong fibrotic interposed tissue, preventing scapho-metacarpal impingement. The mean height of the trapeziectomy space (8.4mm) was maintained upon active pinch and maximal traction on the thumb. A significant atrophy of thenar muscles was also demonstrated, except for the Abductor pollicis brevis. In conclusion, total trapeziectomy with external minifixation provides acceptable clinical results, stabilizes the base of the thumb and prevents scapho-metacarpal impingement. The study brings also important new information about the nature of the interposed tissue in the trapezial space and about the state of the thenar muscles after trapeziectomy.

Pronator quadratus imaging.

Our objectives are to review the sonographic features of the pronator quadratus muscle, to explain the major advantages of ultrasonography as compared to other imaging modalities and to identify the clinical applications in routine wrist ultrasound examination.

[Ultrasound imaging of Dupuytren's contracture]. / Apport de l'échographie dans la maladie de Dupuytren.

Dupuytren's contracture is characterized by two underlying lesions, nodules and cords. These involve the palmar fascia at the distal palmar crease, especially at the level of the third and fourth rays with progressive disabling finger contracture. The superficial palmar aponeurosis appears as a thin echogenic lamellar structure overlying the flexor tendons. The demonstration of hypoechoic bands adhering to the marging of the flexor tendons and deep surface of the dermis appears to be pathognomonic of the disease. Compared to tendons, early nodules are hypoechoic and typically hypervascular whereas older nodules are iso- to hyperechoic, without hypervascular Doppler signal. Ultrasound can sometimes demonstrate arterial encasement by fibrous or scarring tissue. Ultrasound therefore is very useful for the differential diagnosis of pathologies involving the palmar surface of the hand, for the early detection of Dupuytren's contracture, and for the detection of complication, especially vascular. These data may have an impact on management.

[Ultrasound evaluation of the greater occipital nerve]. / Démonstration échographique du nerf grand occipital.

PURPOSE: To demonstrate the appearance of the greater occipital nerve on ultrasound. MATERIALS AND METHODS: The greater occipital nerve was evaluated in 21 patients (9 males-12 females; mean age=52 years, range: 20-71; mean weight=74.5kg, range: 50-125) at the time of carotid duplex ultrasound. All examinations were preformed by the same sonographer using a single ultrasound unit. The anatomical landmark used to locate the nerve was the inferior obliquus capitis muscle. MRI and CT images were available in two cases and anatomical cadaver sections were also available. RESULTS: The greater occipital nerve could be identified at the level of the inferior obliquus capitis muscle in 90.47% (19/21) of cases, even in obese patients. In three slender patients (14.38%), the nerve could be identified at the level of the trapezius aponeurosis and next to the V3 segment of the vertebral artery. The mean anteroposterior diameter of the nerve at the level of the inferior obliquus capitis muscle was 1.65mm (range: 1.14mm-2.8mm). CONCLUSION: The greater occipital nerve could be detected at the level of its first genu by ultrasound in 90% of patients, even in obese patients.

[Sonography of peripheral nerves. Part II: lower limbs]. / Echographie des nerfs périphériques -- Deuxième partie: membre inférieur.

On sonographic images, the peripheral nerves have a fibrillary structure, ribboned on longitudinal images and ovoid on cross-section images. The nerves travel between the muscle groups, often with blood vessels, or in canals. Recently improved ultrasound devices are able to investigate the peripheral nerves along their entire length, as far as the sonographer has thorough anatomical knowledge, rigorous technique, and, when searching for pathology, good clinical notions. As in Part I on sonography of the peripheral nerves of the upper limbs, published in this journal, the objective of this general review is to present normal and pathological echoanatomy of the peripheral nerves of the lower limbs in an educational way.

[Sonography of peripheral nerves--first part: upper limb]. / Echographie des nerfs périphériques--Première partie: membre supérieur.

At sonography, peripheral nerves have a fibrillar appearance, that is tape-like on longitudinal scans and ovoid on transverse scans. Nerves are composed by hypoechoic fascicules within a hyperechoic environment. Less subject to anisotropy and soft to the pressure of the probe, nerves lie between muscles, often with vessels, or within channels. Recent advances in sonographic technology allow accurate imaging of peripheral nerves of the upper and lower limbs, but adequate anatomical and clinical knowledge, as well as rigorous technique are mandatory. The purpose of this general review is to present, as clearly as possible, in two parts, the sonographic features of normal and pathological nerves of upper and lower limbs. This first part will discuss nerves of the upper limb.

Sonoanatomy of the ulnar nerve in the cubital tunnel: a multicentre study by the GEL.

The objective is to determine the normal appearance of the ulnar nerve on a posterior axial sonogram section of the elbow through the medial epicondyle and the humeroulnar joint space. Ultrasound evaluation was carried out on 400 elbows with measurement of the ulnar nerve cross-sectional area and ulnar nerve-cortex distance, as well as recording of apparent ulnar nerve division. Factors that significantly influenced the study variables were sought by statistical analysis. Mean cross-sectional area of the ulnar nerve at the elbow was 7.9 +/- 3.1 mm2 overall. Values were lower in females than in males and increased between 40 and 60 years of age. The ulnar nerve-cortex distance was 0.8 +/- 0.4 mm and varied widely across individuals. Apparent ulnar nerve division at the elbow was noted in about one-fifth of individuals, with no difference between females and males or between the right and left elbows. When present, apparent division was often bilateral and was not associated with changes in cross-sectional area or in distance from the medial epicondyle cortex. This study provides normative data on ulnar nerve sonoanatomy at the elbow and establishes that apparent ulnar nerve division at the elbow is a normal variant.

Ultrasound of the shoulder joint: non "rotator cuff" lesions.

Most of the papers in the literature are on rotator cuff lesions. This paper will deal with a somewhat forgotten part of the shoulder, the joint and the nontendinous structures around the joint. Since 1985, we have performed ultrasound examinations of the shoulder. We have collected many cases and some of them will be performed. The shoulder joint can be partly examined by ultrasound. We can get some information about joint effusions, humeral head cartilage, some part of the labrum, loose bodies, ganglions and fractures around the joint. The acromio-clavicular joint is also part of the examination, leading to diagnosis of sprains, osteoarthritis and dislocations. Non rotator cuff examination of the shoulder must be a routine part of the ultrasound examination of the shoulder.

[Ultrasonography of the wrist and the hand]. / Echographie du poignet et de la main.

There are six large groups of indications for sonographic study of the wrist and the hand: study of nerves, tendons, synovial cysts, ligaments and bony structures, diagnosis of Stener lesion, and search of pulley's abnormalities at the fingers. Use of high frequency probes as well as a gel-pad are required. The examination is essentially delicate, comparative and dynamic. Some structures such as small soft collections may disappear when the pressure of the probe is too heavy. An abnormality may become obvious only by comparison with the normal side, or appear only in a special position, such like synovial cysts. Recognition of osseous landmarks is essential, especially in the study of the wrist.

[Current methods in the diagnosis of deep venous thrombosis of the lower limbs]. / Les méthodes actuelles de diagnostic de la thrombose veineuse profonde des membres inférieurs.

The diagnosis of lower limb deep vein thrombosis requires to use of complementary diagnostic tests. For a long time phlebography has been the only reliable examination and is always regarded as the gold standard by many people. In recent years, non invasive diagnostic modalities have been developed. Most significantly scintigraphy, plethysmography, color Doppler ultrasound and MR imaging. MRI is as reliable as venography but, at the present time, it is time-consuming and far less available than the other modalities. Scintigraphy and plethysmography may be useful but are less accurate and yield a somewhat higher rate of false positive and negative examinations. Color Doppler ultrasound has proved its effectiveness and is currently recommended as the diagnostic modality of choice. Venography is still a significant diagnostic tool for questionable cases or for technically inadequate Doppler ultrasound examinations.

[Contribution of Doppler sonography in inflammatory pathology of the large bowels]. / Contribution de l'échographie Doppler dans la pathologie inflammatoire du tube digestif creux.

At the end of the eighties, Doppler equipment added to conventional ultrasonography a new dynamic dimension. On the basis of radiological (US, CT, barium studies), clinical, biological, surgical and/or pathological correlations in 30 cases, the following considerations were emphasized. In case of intestinal obstruction, viability of the obstructed segment is compromised when Doppler parietal flow remains undetectable. In Crohn's disease or ulcerative colitis, as well as in acute appendicitis, presence of Doppler parietal flow throughout the affected thickened segment indicates an acute condition; similarly, abnormally high mean portal velocity (30-48 cm/sec; normal: 15 +/- 7 cm/sec), and abnormally low resistive index in the superior mesenteric artery (0.58-0.78; normal: 0.908 = 0.026) are detected. In colonic diverticulitis, similar characteristics can be observed, but are subtle and usually predominant at the mesenteric side of the affected segment in moderate diverticulitis. These abnormal Doppler findings disappear with successful therapy.

[diagnostic ultrasonography of air in the portal venous system: apropos of a case of colonic radionecrosis and literature review]. / Diagnostic echographique d'air dans le systeme veineux portal: à propos d'un cas de nécrose colique radique et revue de la littérature.

We present a case of dramatic radiation enterocolitis inducing portal venous air diagnosed by Doppler sonography only. The sonographic pattern consisted of multiple irregular hyperechoic areas into the liver, with internal repetitive noisy bidirectional peaks superimposed on the usual continuous Doppler display of the portal flow. Although portal hyperechoic moving foci alone may reflect only slow portal velocity, they do not create any Doppler distortion as do moving bubbles. Portal air may have multiple causes such as abdominopelvic abscesses, sepsis, intestinal distension, fulminant hepatitis, cholangitis, cholecystitis, diabetic acidosis..., but mesenteric infarct, necrotic enterocolitis, and radiation enteritis are life-threatening conditions that have to be diagnosed as soon as possible. Although large quantities of portal air may be demonstrated on plain film of the abdomen or by computed tomography, Doppler sonography may detect smaller quantities, allowing earlier diagnosis of intestinal pathology requiring immediate surgical treatment. Therefore, Doppler sonography of the liver should be performed in any patient with acute abdominal pain or distension, especially if being treated by abdominal radiotherapy.

Benign gastric ulcers: diagnosis and follow-up with double-contrast radiography.

Double-contrast upper gastrointestinal examinations revealed 108 gastric ulcers at the authors' hospital during a recent 1-year period. With use of current double-contrast examination criteria for differentiating benign and malignant ulcers, the radiographic appearance was unequivocally benign in 68 patients, probably benign in 25, probably malignant in 12, and unequivocally malignant in three. Fifty-six patients with benign, probably benign, or probably malignant ulcers underwent endoscopy and biopsy. All 56 had benign ulcers. Another three patients with unequivocally malignant ulcers had endoscopically proved carcinomas. Thus, most suspicious ulcers were benign, but no benign-appearing ulcers were malignant. Follow-up double-contrast studies for 87 ulcers revealed complete ulcer healing in 68 (78%). A residual ulcer scar was observed in 61 of those 68 cases (90%). This experience suggests that double-contrast radiography is a valuable technique for diagnosing benign gastric ulcers and that once diagnosed, typically benign ulcers can be followed up radiographically until completely healed, without need for endoscopic intervention.

[A case of mesenteric venous thrombosis. Review of the literature]. / A propos d'un cas de thrombose veineuse mésentérique (TVM). Revue de la littérature.

A case is presented in which a venous mesenteric thrombosis necessitated an extended small bowel resection. The postoperative follow-up with its complications is presented. Review of the literature.

Drug-induced esophagitis detected by double-contrast radiography.

Patients with esophageal symptoms following drug ingestion underwent double-contrast upper gastrointestinal studies, and radiographic findings are described. Superficial esophageal ulceration and subtle mucosal abnormalities, which have not been seen on single-contrast radiographs, were confirmed on double-contrast radiographs. Erosions or ulcers usually occur in the region of the aortic arch and occasionally lower in the esophagus. Repeat esophagrams after withdrawal of the medication indicate resolution of the symptoms.

The role of single and double-contrast radiography in the diagnosis of reflux esophagitis.

Sixty-seven patients with endoscopically proved esophagitis and 25 patients who had no esophageal disease were examined by double-contrast esophagography, followed by a single-contrast examination. The radiographs were evaluated separately and as a combined examination technique by three independent radiologists in a blind analysis. The respective sensitivities were 77% for the single-contrast examination, 80% for the double-contrast examination, and 88% for the combined examination method with no significant statistical difference (P = 0.05). The sensitivity increased for all methods with an increased severity of esophagitis. False positives more frequently occurred with double-contrast radiography, leading to similar accuracy rates for all methods (74% to 77%). The double-contrast examination technique showed an advantage over single-contrast radiography only if a granular pattern and erosions were the only radiographically detectible features of esophagitis. The use of the combined examination technique is recommended.