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DOI:10.2214/AJR.06.1484
AJR 2007; 188:S10-S12
© American Roentgen Ray Society

Imaging Evaluation of Tendon Sheath Disease: Self-Assessment Module

Catherine C. Roberts1, Patrick T. Liu1 and Felix S. Chew2

1 Department of Radiology, Mayo Clinic College of Medicine, Scottsdale, AZ 85259.
2 Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105.



 
ARRS members earn free CME and SAM credit at www.arrs.org. Go to left-hand menu bar under Publications/Journals/SAM articles.

Address correspondence to F. S. Chew (fchew{at}u.washington.edu).


Abstract
Top
 Abstract
INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 INSTRUCTIONS
 References
 
The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the imaging evaluation of tendon sheath disease.

Keywords: musculoskeletal imaging • tendon sheath


INTRODUCTION
Top
 Abstract
 INTRODUCTION
EDUCATIONAL OBJECTIVES
 REQUIRED READING
 INSTRUCTIONS
 References
 
This self-assessment module on the imaging evaluation of tendon sheath disease has an educational component and a self-assessment component. The educational component consists of five required articles that the participant should read. The self-assessment component consists of six multiple-choice questions with solutions. All of these materials are available on the ARRS Website (www.arrs.org). To claim CME and SAM credit, each participant must enter his or her responses to the questions online.


EDUCATIONAL OBJECTIVES
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
REQUIRED READING
 INSTRUCTIONS
 References
 
By completing this educational activity, the participant will:

  1. Exercise, self-assess, and improve his or her understanding of the imaging evaluation of tendon sheath masses.
  2. Exercise, self-assess, and improve his or her understanding of the imaging of tendon sheath inflammation and infection.


REQUIRED READING
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
INSTRUCTIONS
 References
 
(available online at www.arrs.org)

  1. Liu PT. Radiological reasoning: acutely painful swollen finger. AJR 2007; 188:S13-S17
  2. Fox MG, Kransdorf MJ, Bancroft LW, Peterson JJ, Flemming DJ. MR imaging of fibroma of the tendon sheath. AJR 2003; 180:1449-1453
  3. Ly JQ, Carlson CL, LaGatta LM, Beall DP. Giant cell tumor of the peroneus tendon sheath. AJR 2003; 180:1442
  4. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR 2004; 183:337-339
  5. Hsu CY, Lu HC, Shih TT. Tuberculous infection of the wrist: MRI features. AJR 2004; 183:623-628


INSTRUCTIONS
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 INSTRUCTIONS
References
 

  1. Complete the required reading.
  2. Visit www.arrs.org and go to the left-hand menu bar under Publications/Journals/SAM articles.
  3. Using your member login, order the online SAM as directed.
  4. Follow the online instructions for entering your responses to the self-assessment questions and complete the test by answering the questions online.


QUESTION 1

Regarding soft-tissue masses of the hand, which entity could have an MRI appearance similar to giant cell tumor of the tendon sheath?

  1. Palmar fibromatosis.
  2. Synovial chondromatosis.
  3. Fibroma of the tendon sheath.
  4. Hemangioma.
  5. Ganglion cyst.

 


QUESTION 2

Regarding the incidence and distribution of fibroma of the tendon sheath and giant cell tumor of the tendon sheath, which of the following statements is TRUE?

  1. Both lesions most often occur in the upper extremities.
  2. Fibroma of the tendon sheath is more common in the lower extremities.
  3. Giant cell tumor of the tendon sheath is less common than fibroma of the tendon sheath.
  4. Fibroma of the tendon sheath is more common in older patients.
  5. Both lesions are more common in women.

 


QUESTION 3

Which MRI characteristic is most specific for giant cell tumor of the tendon sheath?

  1. T2-weighted signal intensity similar to that of muscle.
  2. High internal T1-weighted signal intensity.
  3. Intense, homogeneous enhancement with gadolinium.
  4. Blooming artifact on gradient-echo sequences.
  5. High internal signal on STIR sequences.

 


QUESTION 4

Sonography of giant cell tumor of the tendon sheath most often shows which of the following characteristics?

  1. Homogeneous, hypoechoic mass with internal vascularity.
  2. Homogeneous, hypoechoic mass with erosion of underlying bone.
  3. Homogeneous, hypoechoic mass that moves with adjacent tendon.
  4. Heterogeneous, cystic mass with peripheral vascularity.
  5. Heterogeneous, cystic mass with internal calcification.

 


QUESTION 5

Which MRI feature favors tenosynovitis caused by inflammatory arthritis over tuberculous infection of the wrist?

  1. Bone erosion.
  2. Rim-enhancing abscess.
  3. Homogeneous fluid signal in the tendon sheath.
  4. Low T2-signal thickened synovium.
  5. Median nerve encasement.

 


QUESTION 6

Regarding MRI of tendon sheath disorders, which feature best differentiates infection from a soft-tissue neoplasm?

  1. Thickened tenosynovium.
  2. Involvement of multiple tendon sheaths.
  3. Fluid in the tendon sheath.
  4. Low T1- and T2-weighted signal foci.
  5. Areas of enhancement.

 

Solution to Question 1
Fibromas can present as soft-tissue masses that are similar to giant cell tumors within or adjacent to tendon sheaths [1]. They usually appear isointense to skeletal muscle on T1-weighted sequences and isointense to hypointense on T2-weighted sequences, but they may have areas of high T2 signal, depending on their mixture of fibrous and myxoid composition. Option C is the best response. Palmar fibromatosis, or Dupuytren's contracture of the hand, has thin chord-shaped collections of fibrous tissue in the fingers. The lesions in palmar fibromatosis are more elongated and much less bulky than a giant cell tumor of the tendon sheath. On MRI, the collagen deposits have homogeneous, low, very hypointense signal relative to skeletal muscle on both T1- and T2-weighted sequences in the fingers, and the linear lesions are located in the subcutaneous fat of the hand, not associated with tendon sheaths. Option A is not the best response. Synovial chondromatosis can occur in tendon sheaths but usually presents with large amounts of tendon sheath fluid and multiple small loose ovoid bodies. Option B is not the best response. Hemangiomas commonly have hyperintense signal on T2-weighted images, similar to water, occasionally with phleboliths or flow voids. Option D is not the best response. Ganglion cysts can arise from tendon sheaths but have signal characteristics similar to water on all sequences. Option E is not the best response.

Solution to Question 2
Fibroma of the tendon sheath and giant cell tumor of the tendon sheath can be difficult to differentiate on clinical examination, imaging, and gross pathology [2]. In some cases, demographic and location information can assist with the differential diagnosis. Both lesions occur most commonly in the upper extremities [2]. Option A is the best response. Fibroma of the tendon sheath is less common in the lower extremities. Thus, a lower extremity lesion is more likely to be a giant cell tumor of the tendon sheath. Option B is not the best response. Overall, giant cell tumor of the tendon sheath is more common than fibroma of the tendon sheath by a ratio of 2.7:1 [2]. Option C is not the best response. Both lesions are most common in men in their 30s, although fibroma of the tendon sheath has a slightly lower average age and a stronger predilection for men [2]. Options D and E are not the best responses.

Solution to Question 3
Giant cell tumor of the tendon sheath typically contains hemosiderin. The presence of hemosiderin in these lesions causes a blooming artifact on gradient-echo images [3]. Option D is the best response. The appearance of giant cell tumor of the tendon sheath is somewhat inconsistent on T1- and T2-weighted sequences because of the varying composition of fibrous and inflammatory elements. Fibrous elements have low signal on T1- and T2-weighted images. Option A is not the best response. On T1-weighted images, the masses contain regions of low signal as a result of the fibrous tissue, with the remainder of the mass having a signal similar to that of skeletal muscle. Option B is not the best response. Giant cell tumor of the tendon sheath has variable, heterogeneous enhancement. Option C is not the best response. High signal on STIR sequences can be seen in a giant cell tumor of the tendon sheath, but it is not typical. Option E is not the best response.

Solution to Question 4
In a review of sonographic features of 12 giant cell tumors of the tendon sheath, the most common appearance was a solid, homogeneous, hypoechoic mass that was associated with a tendon and contained internal vascularity [4]. Vascular flow internal to the mass, being peripheral, central, or both, is typically detectable by Doppler examination. Option A is the best response. Pressure erosion of the underlying bone was an uncommon finding. Option B is not the best response. Although the masses are located in the tendon sheath, they arise from the synovial cells [2] and are separate from the tendon. Thus, when the associated body part is flexed or extended, the tendon moves but the mass does not [4]. Option C is not the best response. Giant cell tumors of the tendon sheath can be inhomogeneous on sonography, but this is less common than a homogeneous appearance. None of the masses in the study by Middleton et al. [4] had cystic areas or calcification. Options D and E are not the best responses.

Solution to Question 5
Inflammatory tenosynovitis can have an MRI appearance that is similar to tuberculous infection. Of the characteristics listed, having simple, homogeneous fluid signal in the tendon sheath would be more typical for inflammatory tenosynovitis. Tuberculous infection can have heterogeneous synovial fluid with scattered foci of low signal on T1- and T2-weighted sequences [5]. Option C is the best response. The remainder of the listed characteristics, including bone erosion, rim-enhancing abscess, low T2-signal thickened synovium, and median nerve encasement, are more commonly seen in tuberculous infection [5]. Options A, B, D, and E are not the best responses.

Solution to Question 6
Tendon sheath neoplastic entities tend to be localized processes. Involvement of multiple tendon sheaths and involvement of long segments of the tendon sheath would be more typical of infection. Option B is the best response. Thickened tenosynovium and tendon sheath fluid can be seen in both neoplastic and inflammatory processes. Options A and C are not the best responses. Thickened tenosynovium can be difficult to differentiate from tendon sheath fluid on T2-weighted images. Gadolinium enhancement can aid differentiation of tenosynovium, which enhances, from nonenhancing tendon sheath fluid [5]. Foci of low T1- and T2-weighted signal can be seen in both neoplastic and infectious entities. The low signal in fibromas is due to fibrous tissue. Low signal in giant cell tumor of the tendon sheath is due to hemosiderin and fibrous tissue. Tiny foci of low T1- and T2-weighted signal can be seen in synovial fluid of tuberculous infection, rheumatoid arthritis, and seronegative inflammatory arthropathies [5]. These tiny foci have been postulated to be due to rice bodies, tissue debris, or caseous material [5]. Option D is not the best response. The use of gadolinium does not accurately differentiate tumor and inflammation because each can have a variable amount of enhancement. Option E is not the best response.


References
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 INSTRUCTIONS
 References
 

  1. Liu PT. Radiological reasoning: acutely painful swollen finger. AJR 2007; 188:S13 -S17[Abstract/Free Full Text]
  2. Fox MG, Kransdorf MJ, Bancroft LW, Peterson JJ, Flemming DJ. MR imaging of fibroma of the tendon sheath. AJR2003; 180:1449 -1453[Abstract/Free Full Text]
  3. Ly JQ, Carlson CL, LaGatta LM, Beall DP. Giant cell tumor of the peroneus tendon sheath. AJR 2003;180 : 1442[Free Full Text]
  4. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR 2004; 183:337 -339[Abstract/Free Full Text]
  5. Hsu CY, Lu HC, Shih TT. Tuberculous infection of the wrist: MRI features. AJR 2004;183 : 623-628[Abstract/Free Full Text]

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This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow CME/SAM Credit
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Roberts, C. C.
Right arrow Articles by Chew, F. S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Roberts, C. C.
Right arrow Articles by Chew, F. S.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

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