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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 5  |  Page : 22-28

Regional sonology of the upper limb - II: Wrist and hand

1 Eclat Polyclinic, Mumbai, Maharashtra, India
2 Gray Scale Imaging, Vile Parle (West), Mumbai, Maharashtra, India

Date of Web Publication1-Aug-2018

Correspondence Address:
Dr. Ankit B Shah
102, Kusumkunj, 10th Road, Khar (West), Mumbai - 400 052, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-3698.238198

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With the advent of musculoskeletal ultrasound (US), there has been a paradigm shift in the way rheumatological conditions are detected, quantified and managed. Small joints of the wrist and hand play an important role in the diagnosis and characterization of inflammatory arthritis. Successful scanning of the wrist and hand requires good scanning equipment, thorough knowledge of anatomy and scanning protocols. The dorsal recesses of the wrist, metacarpophalangeal joint, proximal interphalangeal joint and the distal interphalangeal joint are scanned to look for joint effusion, synovial hypertrophy and cortical erosions. The extensor tendons of the wrist and hand have a synovial sheath at the level of the distal radius. The flexor tendons and the median nerve along the volar aspect of the wrist pass through a fibro-osseous tunnel known as the carpal tunnel. US pathologies commonly encountered in inflammatory arthritis have been very well defined in literature, so that there is better reproducibility of the tests and reduction in the inter-observer variation.

Keywords: Effusion, erosions, musculoskeletal ultrasound, power doppler, synovial hypertrophy

How to cite this article:
Shah BR, Shah AB. Regional sonology of the upper limb - II: Wrist and hand. Indian J Rheumatol 2018;13, Suppl S1:22-8

How to cite this URL:
Shah BR, Shah AB. Regional sonology of the upper limb - II: Wrist and hand. Indian J Rheumatol [serial online] 2018 [cited 2022 Oct 3];13, Suppl S1:22-8. Available from:

  Introduction Top

Application of musculoskeletal ultrasound (US) in rheumatoid arthritis (RA) was first described by Cooperberg in 1978,[1] wherein they assessed synovitis in the knee joint. In 1994, J.S. Newman described the use of Power Doppler (PD) in assessment of soft tissue hyperemia.[2] Ever since then, PD has gradually replaced gray-scale US as a marker for inflammation. Due to recent advances in transducer technology, there has been marked improvement in image resolution of US. Higher resolution and the ability to image much smaller structures are one of the many advantages of US over magnetic resonance imaging.[3] Apart from detection, US also allows monitoring and prognostication of patients having RA.

Small joints of the hand play a pivotal role in the diagnosis and characterization of inflammatory arthritis. A systematic US examination should include assessment of the extra-articular structures i.e., subcutaneous tissues, tendon, tendon sheath, the enthesis and the bursae. The joints should be assessed for detection and characterization of effusion, synovial hypertrophy and cortical erosions. Successful scanning of the wrist and hand requires adequate knowledge of anatomy and the scanning techniques. The aim of this article is to make the reader familiar with the US anatomy of the commonly scanned structures in wrist and hand and the US appearance of common pathologies seen in patients with inflammatory arthropathy.

  Scanning Technique Top

The standard US scanning technique of the wrist is done with the patient seated opposite to the examiner and the patient's hand resting on the examination table. Scanning is done using a high-frequency 12–18 MHz linear-array probe. High resolution transducers with a small foot-print or hockey-stick transducers allow the examiner to navigate difficult areas such as the finger web spaces. A large amount of gel is used over the scanned area. The excessive gel serves as a stand-off pad allowing adequate visualization of the most superficial structures such as the skin and the subcutaneous tissues. It is advisable to use minimal probe pressure while scanning, since excessive pressure can displace small volume of fluids and obliterate the blood flow. The regions of interest are scanned in the longitudinal and the transverse planes. Wherever possible, extended field-of-view or Panoramic imaging is recommended so as to demonstrate the maximum anatomy. The fingers should be imaged in neutral position with mild degree of flexion- especially when imaging with PD.[4] For Doppler settings, a Pulse Repetition Frequency from 500 to 750 Hz is recommended.

  Anatomy Top


Due to their superficial location and paucity of overlying subcutaneous fat, the joints of the wrist and the hand can be easily assessed with US. Radio-ulno-carpal, intercarpal, carpo-metacarpal and the distal radio-ulnar joints are assessed while scanning the wrist. Metacarpophalangeal (MCP) [Figure 1], proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joints are evaluated when scanning the hand. Long-axis views of the joints are most commonly used for diagnostic US. The dorsal recesses of the wrist are assessed along two articulations: (1) between radius and lunate and (2) between lunate and capitate [Figure 2]. The joints are scanned along the long-axis by sweeping the probe from radial to ulnar aspects. Additional short-axis views may be used at the level of the MCP and distal radio-ulnar joints.
Figure 1: Long-axis image of the metacarpophalangeal joint shows the extent of the dorsal recess (asterisks) till the metacarpal neck. The articular cartilage is seen as a homogenously hypoechoic strip (triangles)

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Figure 2: Dorsal recesses of the wrist are divided into radio-carpal and the intercarpal recesses. Long-axis image along the dorsum of the wrist shows normal recess (asterisk) between the radius and lunate. Mild effusion is seen in the intercarpal recess (triangle). RAD: Radius, LUN: Lunate, CAP: Capitate

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On US, the cortex is seen as a well-demarcated uninterrupted hyperechoic line with distal shadowing. The normal cartilage, evaluated on long-axis images, is visualized as a homogenous anechoic band.[5] The cartilage over the metacarpal head is well-visualized with flexion at the MCP joint. The normal cartilage thickness over the metacarpal head varies between 0.2 and 0.5 mm.[4] Normal subjects have a mildly echogenic intra-articular fat pad along with a thin rim of effusion. Intra-capsular but extra-synovial loose fat is seen interposed between the flexor tendons and the cortex of the phalanges at the level of the interphalangeal joints [Figure 3]. Anisotropy may result in the loose fat being erroneously diagnosed as pannus.
Figure 3: Volar recess of the metacarpophalangeal joint (triangle) as seen on the long-axis view. MC: Metacarpal, PP: Proximal phalanx, *: Volar plate. FDS: Flexor Digitorum Superficialis, FDP: Flexor Digitorum Profundus

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One of the most common indications of US of hand and wrist is assessment of tendon pathology. The normal tendon consists of Type I collagen fascicles which are oriented parallel along the long-axis of the tendon [Figure 4]. On US scanning of the tendon along its long axis, the tendon has an echogenic fibrillar appearance. On the short-axis view, the tendon is seen as a rounded or an oval echogenic structure with multiple dot-like echoes or a typical “brush-pattern” appearance.
Figure 4: Normal fibrillary echogenic pattern of the Extensor Carpi Ulnaris tendon (triangles) as seen along its long-axis

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Along the dorsal aspect of the wrist, the extensor tendons are covered by the Extensor retinaculum. Fibrous septae arising from the extensor retinaculum divide the extensor tendons into six compartments. The compartments are labeled from I to VI from radial till ulnar aspects of the wrist. Compartment I consists of Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) tendons. Compartment II consists of Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis tendons. Lister's tubercle is an osseous ridge along the dorsal aspect of the radius, dividing Compartment II and III tendons and is an important anatomical landmark during US scanning of the wrist [Figure 5]. Extensor Pollicis Longus lies (EPL) within compartment III of the wrist. Compartment IV tendon is made up of Extensor Digitorum Longus tendons. Extensor Digiti Quinti lies in extensor Compartment V and is seen to overly the distal radio-ulnar joint [Figure 6]. Extensor Carpi Ulnaris (ECU) is seen in Compartment VI of the extensor tendons of the wrist. The ECU lies within an osseous groove of the Ulna [Figure 7]. The extensor tendons are surrounded by a synovial sheath at the level of the extensor retinaculum.
Figure 5: The Lister's tubercle is identified as an osseous projection (triangle) along the dorsal surface of the distal radius, separating extensor compartments II and III, RAD: Radius

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Figure 6: Extensor compartment IV tendons of the wrist lie immediately radial to the extensor pollicis longus tendon. The extensor compartment V tendon is located above the distal radio-ulnar joint, DRUJ: Distal radio-ulnar joint

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Figure 7: On the short-axis, the extensor carpi ulnaris tendon (asterisk) is seen to rest in the ulnar groove (triangles)

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Distally, the tendons traverse along the dorsal aspect of the hand and insert at the base of the middle and distal phalanges. The EPL inserts over the base of the distal phalanx of the thumb [Figure 8]. Each of the extensor tendons inserting over the index, middle, ring and little fingers divide into central and lateral slips as they course distally. The central slip inserts over the base of the middle phalanx whereas the lateral slips insert over the base of the terminal phalanx. The extensor tendons are devoid of a synovial sheath at the level of the hand. At the level of the metacarpal head, the extensor tendons are covered by organized fibrous connective tissue known as the extensor hood. The extensor hood stabilizes the tendons during motion.
Figure 8: Long-axis sections along the dorsum of the thumb show attachment of the extensor pollicis longus tendon (white arrows) along the base of the terminal phalanx of the thumb

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The carpal tunnel located along the volar aspect of the wrist, is a fibro-osseous space bound by the carpal bones along the dorsal aspect and the flexor retinaculum along the volar aspect. The proximal carpal tunnel is identified by identifying the scaphoid tubercle along the radial aspect and the pisiform along the ulnar aspect [Figure 9] The trapezium tubercle along the radial aspect and the hook of hamate along the ulnar aspect form the osseous landmarks for the distal carpal tunnel. The proximal carpal tunnel space is smaller compared to the space in the distal carpal tunnel.[6] The carpal tunnel contains the median nerve, flexor tendons of the fingers and the flexor pollicis longus tendon.
Figure 9: Short-axis image the level of the proximal carpal tunnel shows the location of the median nerve (asterisk) just below the flexor retinaculum (triangles). The proximal carpal tunnel is identified by Pisiform (Pisi) along the ulnar aspect and Scaphoid (Sca) along the radial aspect. F-Flexor Digitorum Superficialis and flexor digitorum profundus tendons, FCR: Flexor Carpi Radialis tendon

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All the flexor tendons of the wrist pass through the carpal tunnel other except the Flexor Carpi Radialis, Flexor Carpi Ulnaris and the Palmaris Longus tendons. Flexor tendons within the carpal tunnel have a common synovial sheath. The Flexor Pollicis Longus inserts over the base of the distal phalanx of the thumb. Flexion of the index, middle, ring and little fingers is brought about by Flexor Digitorum Superficialis (FDS) and Flexor Digitorum Profundus (FDP) tendons. The FDS and FDP traverse the volar aspect of hand in close approximation, where the FDS tendon lies volar to the FDP tendon [Figure 10]. At the level of the proximal third of the proximal phalanx, the FDS divides into two slips that pass on either side of the FDP tendon and unite once again (deep to the FDP) before inserting over the base of the middle phalanx. The FDP continues distally insert over the base of the terminal phalanx. Distal to the level of the metacarpal neck, the FDS and FDP are covered by a common synovial sheath.
Figure 10: Long-axis image at the level of the metacarpophalangeal joint. FDS: Flexor Digitorum Superficialis, FDP: Flexor Digitorum Profundus

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The FDS and FDP are held in place by a series of fibrous bands known as the pulleys. Apart from preventing anteroposterior and lateral excursion of the flexor tendons away from the MCP and the interphalangeal joints during flexion, the pulleys also provide a fulcrum where the flexor tendons can exert sufficient force.[7] According to the morphology, the pulleys are divided into Annular (A1, A2, A3, A4, A5) and Cruciate (C1, C2, C3) pulleys. The A1 pulley is located at the level of the MCP joint and extends till the base of the proximal phalanx. The A2 pulley is the strongest pulley and is located at the level of mid-shaft of the proximal phalanx. A3 and A5 pulleys are located at the levels of the PIP and DIP joints respectively. The A4 pulley is located at the level of the middle phalanx. The annular pulleys are best assessed on the transverse images and are visualized as anisotropic bands [8] [Figure 11]. The volar-most segment of the annular pulley is seen as an echogenic fibrillar structure close to the mid-line. Due to the anisotropy, the lateral arms of the pulley are seen as hypoechoic structures fanning out on either side of the flexor tendons.
Figure 11: Short-axis image at the level of the metacarpophalangeal joint shows the normal A1 pulley (white arrows). FDS: Flexor Digitorum Superficialis tendon. FDP: Flexor Digitorum Profundus tendon

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Median and ulnar nerves

The median nerve is located superficially to the FDS tendons in the carpal tunnel, just below the flexor retinaculum. The Median nerve is examined in long and short axis views. The nerve lies parallel to the flexor tendons and has a typical fascicular pattern on the long-axis views. On the short-axis, the nerve is seen as an elliptical structure having a typical “honey-comb” appearance where the hypoechoic nerve fascicles are surrounded by an echogenic epineurium [Figure 12]. Cross-sectional area of the median nerve is obtained in the proximal carpal tunnel at the level of the Pisiform bone. A median nerve having a cross-sectional area more than 10 mm 2 is considered to be enlarged.[9] Bifid median nerve is considered to be an anatomical variant and is often accompanied by a persistent median artery.
Figure 12: Long-axis image (a) through the normal median nerve shows the normal fascicular pattern (arrows). Short-axis image (b) show the honey-comb pattern (pointer) of the normal nerve. RAD: Radius

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At the level of the wrist, the ulnar nerve lies in a fibro-osseous tunnel known as the Guyon's canal. The Guyon's canal containing the ulnar nerve and the artery, is located along the ulnar aspect of the proximal carpal tunnel and is formed by the flexor retinaculum, proximal carpal ligaments and the pisiform bone. The nerve is located immediately adjacent to the Ulnar artery (which can be identified by using Colour Doppler).

  Pathology Top

US has been often regarded as an operator-dependent imaging modality. Lack of standardization results in poor reproducibility of the images and inter-observer variation in image interpretation. To overcome these limitations, standard definitions for commonly encountered US pathologies have been introduced by Outcome Measures in Rheumatology and US special interest group.[10]

  Joints Top

Effusion and synovial hypertrophy

On US, joint fluid is seen as hypoechoic or anechoic intra-articular material that is compressible, bust does not show Doppler signal.[10] Synovial hypertrophy is seen as intra-articular abnormal hypoechoic tissue that is poorly compressible [Figure 13] and may exhibit Doppler signal.[10] Joint effusion occurs early in inflammatory arthritis. Dorsal recesses of the wrist whereas dorsal and volar recesses of the MCP, PIP and DIP should be scanned to look for effusion and synovial hypertrophy.[11],[12] Synovial hypertrophy is more commonly visualized along the radial aspect of the PIP joint.[13] Disease activity of the pannus is determined by assessing synovial hyperemia on PDUS. On PDUS, a semiquantitative scoring system is used as follows: Grade 0- Absence of signal, Grade 1 (mild)-Upto 3 single vessel signals or 2 single vessels plus 1 confluent signal, Grade 2 (moderate)– Signal occupying <50% of the synovium and Grade 3 (marked)– vessels signal in more than 50% of the synovial area [14] [Figure 14]. Criteria used for US monitoring of therapy include reduction in the thickness of pannus and change in synovial hyperemia.
Figure 13: Echogenic appearance of pannus (asterisks) along the dorsal recess of the metacarpophalangeal joint in a patient with Rheumatoid arthritis. MC: Metacarpal, PP: Proximal phalanx

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Figure 14: Patient with Psoriasis. Doppler images show marked hyperemia (Grade III) in the thickened synovium along the dorsal recess of the metacarpophalangeal joint. Anechoic effusion (asterisk) also seen within the joint. MC: Metacarpal, PP: Proximal phalanx

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Joint erosions are defined as intra-articular discontinuities of the bone surface visualized in two perpendicular planes [10] [Figure 15]. US is more sensitive than plain radiographs in the detection of bone erosions.[15] Hence, the primary objective of performing US is to detect cortical erosions before they become evident on radiographs. The erosions are considered small when they measure <2 mm. Moderate sized erosions measure between 2 and 4 mm whereas large erosions measure more than 4 mm.[15]
Figure 15: Cortical erosions (arrows) seen in the metacarpal head along the dorsal recess of metacarpophalangeal joint

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Chronic inflammation of the joint results in development of secondary osteoarthritis (OA). Osteophytes are considered to be hallmarks of OA. Osteophytes are visualized as peri-articular protrusions in two planes [Figure 16].
Figure 16: Long-axis section through the carpometacarpal joint along the thumb base shows marginal osteophytes (arrows)

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On US, enthesopathy is seen as hypoechoic and/or thickened tendon or ligament along its osseous attachment and may exhibit Doppler signal and/or bony changes.[10]

  Tendons Top

In patients with inflammatory arthritis, the spectrum of pathologies involving the tendons include tenosynovitis, tendinosis, tendon tear (partial/full thickness) and enthesopathy.

Tenosynovitis is defined as hypoechoic or anechoic thickened tissue with or without fluid in the tendon sheath [Figure 17] and [Figure 18], which is seen in two perpendicular planes and which may exhibit Doppler signal.[10] Common causes of tenosynovitis include inflammatory conditions, infective conditions and overuse syndromes. De Quervain's tenosynovitis, involves compartment I of the extensor tendons of the wrist. It is an overuse syndrome caused due to repeated strain on APL and EPB tendons by the thickened extensor retinaculum. Tenosynovitis commonly involves extensor compartment IV tendons in inflammatory arthritis. Giant cell tumors may mimic tenosynovitis and cause a diagnostic dilemma.
Figure 17: In a patient with Psoriasis, section along the short-axis of extensor compartment IV tendons shows effusion (arrows) within the tendon sheath. Asterisk-tendon

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Figure 18: Long-axis view through the flexor tendons of the wrist show synovial hypertrophy (arrows) with anechoic effusion within the flexor tendon sheath

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US diagnostic features of tendinosis include tendon enlargement along with hypoechogenicity of the tendon and loss of fibrillary appearance [Figure 19]. Chronic tendinosis may result in interstitial tears along with intra-tendinous calcification. Tendon tears are seen as anechoic or hypoechoic defects on US.
Figure 19: Short-axis image of the extensor carpi ulnaris tendon shows a tendon enlargement with marked heterogeneity (arrow) suggestive of tendinosis

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  Median Nerve Top

The median nerve is often compressed by the flexor retinaculum as it passes through the carpal tunnel. This condition is known as carpal tunnel syndrome (CTS). Diabetes mellitus, pregnancy, hypothyroidism and space occupying lesions within the carpal tunnel are some of the common predisposing factors resulting in CTS. The diagnosis of CTS is primarily based on clinical examination and nerve conduction studies. The role of US is to assess the median nerve morphology, quantification of median nerve enlargement and identify any space occupying lesions (ganglia, tenosynovitis, etc.) within the carpal tunnel. The compressed median nerve appears enlarged and hypoechoic in the proximal tunnel and flattened in the distal half of the carpal tunnel [Figure 20]. The hypoechoic nerve loses its fascicular pattern. The median nerve is considered abnormal when the cross-sectional area is more than 10 mm 2. PD may demonstrate intraneural and perineural hyperemia.
Figure 20: In a patient with clinical symptoms of carpal tunnel, long-axis view through the median nerve shows flattening (arrows) of the nerve within the carpal tunnel. Thickening of the proximal nerve (asterisk) represents intraneural edema

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  Conclusion Top

US should be considered as the primary imaging modality in the detection and quantification of pathology in inflammatory arthritis. Unlike other joints, superficial location of the joints and the tendons in the wrist and hand makes them far more simple to assess with high resolution US. Knowing the relevant anatomy of wrist and hand is the key to successful assessment and interpretation of the US study. Appropriate use of high resolution transducers facilitates in better characterization of the lesions.

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  References Top

Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978;126:759-63.  Back to cited text no. 1
Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hyperemia: Value of power doppler sonography. AJR Am J Roentgenol 1994;163:385-9.  Back to cited text no. 2
Neumann T, Ermert H. Schlieren visualization of ultrasonic wave fields with high spatial resolution. Ultrasonics 2006;44 Suppl 1:e1561-6.  Back to cited text no. 3
Filippucci E, Iagnocco A, Meenagh G, Riente L, Delle Sedie A, Bombardieri S, et al. Ultrasound imaging for the rheumatologist II. Ultrasonography of the hand and wrist. Clin Exp Rheumatol 2006;24:118-22.  Back to cited text no. 4
Grassi W, Tittarelli E, Pirani O, Avaltroni D, Cervini C. Ultrasound examination of metacarpophalangeal joints in rheumatoid arthritis. Scand J Rheumatol 1993;22:243-7.  Back to cited text no. 5
Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Berlin – Heidelber, New York: Springer Google Scholar; 2007.  Back to cited text no. 6
Rispler D, Greenwald D, Shumway S, Allan C, Mass D. Efficiency of the flexor tendon pulley system in human cadaver hands. J Hand Surg Am 1996;21:444-50.  Back to cited text no. 7
Boutry N, Titécat M, Demondion X, Glaude E, Fontaine C, Cotten A, et al. High-frequency ultrasonographic examination of the finger pulley system. J Ultrasound Med 2005;24:1333-9.  Back to cited text no. 8
Klauser AS, Halpern EJ, De Zordo T, Feuchtner GM, Arora R, Gruber J, et al. Carpal tunnel syndrome assessment with US: Value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology 2009;250:171-7.  Back to cited text no. 9
Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D'Agostino MA, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005;32:2485-7.  Back to cited text no. 10
Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Rheum 2009;61:1194-201.  Back to cited text no. 11
Østergaard M, Szkudlarek M. Ultrasonography: A valid method for assessing rheumatoid arthritis? Arthritis Rheum 2005;52:681-6.  Back to cited text no. 12
Backhaus M, Burmester GR, Gerber T, Grassi W, Machold KP, Swen WA, et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001;60:641-9.  Back to cited text no. 13
Dougados M, Jousse-Joulin S, Mistretta F, d'Agostino MA, Backhaus M, Bentin J, et al. Evaluation of several ultrasonography scoring systems for synovitis and comparison to clinical examination: Results from a prospective multicentre study of rheumatoid arthritis. Ann Rheum Dis 2010;69:828-33.  Back to cited text no. 14
Wakefield RJ, Gibbon WW, Conaghan PG, O'Connor P, McGonagle D, Pease C, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: A comparison with conventional radiography. Arthritis Rheum 2000;43:2762-70.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]


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