High resolution ultrasonography of the hand and wrist: three-year experience at a District General Hospital Trust.

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.

Posterior interosseous nerve palsy in rheumatoid arthritis: case report and literature review.

Posterior interosseous nerve (PIN) palsy, presenting with a loss of digital extension, is a rare neurological complication of rheumatoid arthritis (RA). It may be caused by nerve entrapment, vasculitis or drug toxicity. There is no consensus regarding the treatment of PIN palsy in RA. We present a case in which the diagnosis of PIN palsy was confounded by previous surgical intervention. It represents the first report of PIN palsy treated with anti-TNF-alpha therapy leading to full recovery without surgical intervention. We highlight the importance of electrophysiological studies in elucidating the underlying cause and hence the treatment. We suggest that the apparent success of surgical intervention in the literature may be misleading, but new pharmacological advances may obviate the need for surgery where electrophysiology demonstrates vasculitis as the cause. A literature review is presented and a treatment algorithm proposed.