What are the best ways to examine the hand status?



This is my first post on this forum. I simply wonder what the best ways to examine a hand, wrist and arm are? I want to have a clear picture of not only the nerve, but the tendons, bones, blood vessels, muscles etc as well.

Is it MRi?
Is it ultrasound?
Is it X-ray?
Is it ENMG?

I want to know the positions of all things inside of the hand and wrist, how swollen the tendons are, if there are any bones that look to have been broken, how the blood flow looks like etc.

I should perhaps tell you that there were some surpises when they did the surgery on my hand in March 2013. There were alot of blood vessels that shouldn't be inside of the hand, he said. So they took most of the time during the surgery to remove them first of all. The blood vessels were around and pressing on the nerve in the center of the carpal tunnel and even grew into the nerve. So the median nerve looked like pink instead of its normal yellow colour, he said. I also got some atrophy in my thumb muscle, but I wouldn't say the grip is bad. They told me to wait a year before possibly having a surgery done on my left hand as well. But I haven't done any tests before the surgery, except from the manual 2-point, Durkan and Tinell plus the Italian new one tests. The surgeon told me, "in my case some tests in advance should have been done, but normally we don't do them". Now it seems my left hand must have a surgery and possible my right hand again, since the problems come back.

Is a MRi best? Or a combination?


That's a rather interesting surgical story. One extra blood vessel is quite often seen in the carpal tunnel. It's called the median artery and is found in about 1% of the population but what your surgeon is describing sounds more like an arteriovenous malformation in the area - something I can't remember ever having seen reported. We do tend to be built symmetrically so there is always the possibility that whatever you had in the right hand might be found in the left too and I would certainly want to investigate that before operating on it.

Which modality is best depends on what you want to see. Ordinary X-rays are really good at showing bone structure in great detail but relatively poor for soft tissue - you cannot for example distringuish the nerves at all. CT-scanning shows more soft tissue detail but not as much as MRI so most people would opt for MRI for a detailed radiological assessment of the carpal tunnel region when you are looking for what may be a very rare abnormality. There is also a lot to be said for ultrasound imaging, unlike the static pictures of MRI the ultrasound allows you to watch the nerve and tendons move in real time as the wrist and fingers move and you can detect blood flow in vessels and hypervascularity of tissue with doppler imaging. In the direction of the ultrasound beam modern ultrasound scanners offer the highest spatial resolution of any of these methods and it's also much cheaper than MRI. Finally the nerve conduction studies give you completely different physiological information about how well the nerve is working as opposed to what it's structure looks like. In your case I would start with NCS and ultrasound and think about having MRI done as well if the ultrasound suggested there was anything worth looking at. JB

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