Wrist / hand (with and without Doppler)

Wrist / hand (with and without Doppler) — Reference values: Minimum protocol without Doppler, Protocol with Doppler.

Wrist ultrasound should separate anatomic technique, tendon assessment, peripheral nerves and joint inflammation. Doppler is not an “extra”: when synovitis, tenosynovitis, rheumatoid arthritis, infection or vascular mass is suspected, it changes interpretation.

Measurements and reference values

Measurement	Usual value	Note
Minimum protocol without Doppler	dorsal + volar + dynamic	Assess tendons in short and long axis, retinacula, radiocarpal/intercarpal joints, carpal tunnel, Guyon canal and painful point.Source: ESSR wrist guideline / AIUM MSK parameter
Protocol with Doppler	low scale and high gain without artifact	Use for synovitis, tenosynovitis, inflammatory arthritis, peritendinous hyperemia, vascular mass and infection; avoid excessive compression.Source: AIUM / OMERACT-EULAR
Median nerve — cross-sectional area at the carpal tunnel	<10 mm²	Fixed cutoffs vary; 10–12 mm² is a gray zone and >12 mm² is more consistent with compressive neuropathy when symptoms match.usual: <10 mm²borderline: 10–12 mm²enlarged: >12 mm²Source: J Ultrasound Med / Frontiers Neurology / CTS reviews
Median nerve — wrist/forearm ratio	<1,4	Ratio ≥1.4 increases suspicion and reduces body-habitus variation; use wrist area divided by proximal forearm area.usual: <1,4suspicious: ≥1,4Source: Hobson-Webb / J Ultrasound Med
Median nerve — wrist-circumference adjusted limit	0.88 × circumference − 4 mm²	Alternative described to adjust the upper normal limit by wrist circumference in centimeters.Source: Frontiers Neurology 2021
Ulnar nerve in Guyon canal	no universal cutoff	Compare caliber, fascicles, compression, mass/cyst, ulnar artery, bifurcation into superficial sensory branch and deep motor branch.Source: ESSR wrist guideline / AIUM peripheral nerve
Synovitis — OMERACT/EULAR scale	0–3 B-mode and Doppler	B-mode measures synovial hypertrophy; Doppler measures active vascularity. Interpret separately and with clinical context.Source: EULAR-OMERACT / SONAR RA recommendations

Classifications and calculators

Interactive assistant — wrist, nerves and synovitis

Input	How to interpret	Limitation
No synovitis and usual median nerve	Nerve area <10 mm², no synovial Doppler, no tenosynovitis and no erosion.	Correlate with symptoms; ultrasound does not exclude every neuropathy.
Gray zone	Nerve 10–12 mm², isolated ratio ≥1.4, grade 1 synovitis, mild Doppler or tenosynovitis without aggressive signs.	Needs clinical correlation, contralateral comparison and sometimes nerve conduction or rheumatology.
Relevant abnormal	Nerve >12 mm² with high ratio/symptoms, Doppler grade 2–3, B-mode synovitis grade 2–3, erosion, tendon rupture or motor deficit.	Do not close as incidental.

Use as educational triage. The final impression must integrate symptoms, physical exam, symptom distribution and clinical hypothesis.

Source: ESSR / AIUM / EULAR-OMERACT / Frontiers Neurology

Wrist extensor compartments — anatomic map

Compartment	Tendons	Tips and common pathology
1	Abductor pollicis longus + extensor pollicis brevis.	De Quervain tenosynovitis; look for vertical septum and accessory tendons.
2	Extensor carpi radialis longus + extensor carpi radialis brevis.	Crossing point with the first compartment in the distal forearm: intersection syndrome.
3	Extensor pollicis longus.	Use Lister tubercle as landmark; rupture risk in rheumatoid arthritis or attrition.
4	Extensor digitorum + extensor indicis proprius.	Inflammatory tenosynovitis is common; dynamic maneuver separates tendons.
5	Extensor digiti minimi.	Small and ulnar; assess tenosynovitis and rupture in inflammatory arthritis.
6	Extensor carpi ulnaris.	Assess dynamic subluxation, tendinopathy, tenosynovitis and gout/crystal deposition.

Source: ESSR wrist technical guideline / Radiopaedia anatomy

Volar side — carpal tunnel and Guyon canal

Structure	Content / landmark	What to look for
Proximal carpal tunnel	Radial scaphoid and ulnar pisiform; median nerve superficial to flexor tendons.	Median nerve area, fascicular edema, retinaculum, persistent median artery and bifid nerve.
Distal carpal tunnel	Radial trapezium and ulnar hook of hamate.	Flattening, retinacular bowing, cysts, flexor tenosynovitis and masses.
Flexor tendons inside the tunnel	Four flexor digitorum superficialis, four flexor digitorum profundus and flexor pollicis longus.	Flexor tenosynovitis, adhesion, partial tear and inflammatory trigger.
Guyon canal	Ulnar artery radial to ulnar nerve; divide into superficial sensory and deep motor branches.	Cyst/ganglion, ulnar artery thrombosis/aneurysm, compression at hamate hook and deep motor branch lesion.
Flexor carpi radialis tendon	Radial, over scaphoid/trapezium, outside the main carpal tunnel.	Tenosynovitis, tendinopathy and volar radial pain.
Flexor carpi ulnaris tendon	Inserts on pisiform; reference for Guyon canal.	Enthesopathy, calcification, crystal deposition and ulnar pain.

Source: ESSR wrist technical guideline / AIUM MSK parameter

Synovitis and rheumatoid arthritis — OMERACT/EULAR teaching scale

Grade	B-mode: synovial hypertrophy	Doppler: vascularity
0	Absent: no synovial hypertrophy.	Absent: no Doppler signal.
1	Minimal: mild thickening without major bulging.	Minimal: up to a few isolated spots/signals.
2	Moderate: hypertrophy bulges beyond the bone line with flat or concave surface.	Moderate: vascular signals in less than half of the synovial area.
3	Severe: marked hypertrophy with convex surface.	Severe: vascular signals in half or more of the synovial area.

In rheumatoid arthritis, report scanned joints, B-mode grade, Doppler grade, erosions, tenosynovitis and tendon rupture. Persistent Doppler may indicate activity even when clinical disease seems controlled.

Source: EULAR-OMERACT / SONAR recommendations / AIUM

Main wrist differentials

Condition	Useful ultrasound findings	Comment
Carpal tunnel syndrome	Enlarged median nerve, high wrist/forearm ratio, fascicular edema, distal flattening, retinacular bowing, intraneural hypervascularity.	Correlate with sensory territory and nerve conduction when needed.
De Quervain tenosynovitis	First-compartment sheath thickening, fluid, hyperemia and pain on dynamic compression.	Look for septum between abductor pollicis longus and extensor pollicis brevis.
Intersection syndrome	Friction/tenosynovitis where first-compartment tendons cross radial extensors in distal forearm.	Pain is usually more proximal than De Quervain.
Ganglion/synovial cyst	Cystic lesion with posterior enhancement, sometimes visible articular stalk, no internal flow.	If complex, vascularized or solid, reclassify as indeterminate.
Inflammatory arthritis / rheumatoid arthritis	B-mode synovitis, synovial Doppler, marginal erosions, flexor/extensor tenosynovitis and possible ruptures.	Doppler and erosion make suspicion more relevant; integrate with serology and rheumatology.
Gout or crystal disease	Heterogeneous tophi, shadowing, erosions, double contour on cartilage when visible, crystal tenosynovitis.	May mimic infection or inflammatory arthritis.
Infection	Collection, intense hyperemia, suspected purulent tenosynovitis, gas, cellulitis and marked pain.	Clinical urgency; ultrasound helps locate collection and guide aspiration.
Ligament injury/triangular fibrocartilage complex	Ultrasound partially assesses dorsal scapholunate ligament and ulnar triangular complex; use maneuvers and compare.	MRI/MR arthrography may be needed.

Source: ESSR / AIUM / EULAR-OMERACT / MSK reviews

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