Ultrasound in Hand and Upper Extremity Clinic: An Introduction for Patients
You wake up in the middle of the night with burning, tingling numbness in your fingers. You have no idea what’s happening so you do a quick Google search and take some ibuprofen.
After a few days, nothing is working and you’re exhausted.
You call your primary care doctor, whose next available appointment is in three weeks. Once you see them, they inform you they can’t necessarily treat the issue but they initiate a referral to a specialist.
After a longer wait to see the specialist, they indicate a few possible diagnoses that could be the culprit, but they will need to refer you out for further testing and see you back a few weeks later.
Sound familiar?
This is an all-too-common problem in medicine today.
Fortunately, for some issues with the hand and upper extremities, there is a better solution. And it's a return to an old friend. A technology we've used for decades, but one that has rapidly improved recently.
Ultrasound.
What used to require a bulky, expensive machine with poor image quality has rapidly morphed into a pocket-sized wireless device that can be used anytime, anywhere. This has greatly expanded the possible uses for this technology, even day-to-day in a busy physician clinic.
It is increasingly and frustratingly difficult to provide both value and speed to a patient as they navigate today’s US healthcare system.
But ultrasound does both.
Here are the 4 most important takeaways to know about handheld ultrasound in 2024:
1.Ultrasound uses sound waves to create images of the body
In its simplest form, ultrasound is a body imaging technology that uses high-frequency sound waves.
To do this, a small probe is placed directly on the area of interest and emits sound waves that then bounce back off the tissues of the body and are captured by the probe.
Depending on how dense the imaged body tissues are (e.g. hard bone vs a soft blood vessel), the sound wave will travel back to the probe at different speeds and with different strengths. This data is collected and used to form an image in real-time.
Voila. We can see inside your body immediately.
2. Ultrasound is inexpensive, fast, and safe
That's great and all, but you may be wondering...so what? What are the benefits to you of ultrasound for the hand and upper extremity?
Ultrasound is not dangerous
Perhaps the most important benefit of ultrasound is that it has no known associated risk. Different imaging technologies, such as X-rays and CT scans, use a type of signal called ionizing radiation. This can cause damage to cells and can even lead to cancer in high enough doses.
The sound waves used in ultrasound technology pose no known risk to your tissues and are completely pain-free.
Ultrasound is inexpensive
We should all care about this one. Ultrasound machines are becoming more portable and less expensive by the year. The cost to the patient, the insurance companies, and the physician's office all continue to plummet.
The cost of obtaining an ultrasound evaluation is a fraction of what a CT scan or MRI (our best available alternatives) would cost for the same body part.
Ultrasound gives us immediate, real-time answers
Speed is everything. Because the probe is held directly on the skin to collect the sound waves, the images are generated in real-time.
In fact, in our office, I just set up my tablet as the viewing screen so the patient and I can see the images together as we go.
This has numerous distinct advantages:
It's just plain cool to see inside your own body in real time with your doctor
The diagnosis is typically instantaneous
A diagnosis doesn't require any outside referrals to another specialist or to schedule with an imaging center.
Plus, when you schedule with an imaging center, that typically requires another appointment to come back and see your doctor to discuss the results and next steps for treatment.
3. Ultrasound can diagnose and help treat many conditions of the hand & upper extremity
This list grows every day as we get better at using the technology. But let's break down ultrasound use in the hand and upper extremity into a few subcategories:
Ultrasound and carpal tunnel syndrome
If you're familiar with the hand and upper extremities, my guess is you've heard of carpal tunnel syndrome.
This condition and its sibling, cubital tunnel syndrome, are “pinched nerves” that are typically diagnosed with a combination of a doctor's physical examination and a (sometimes) painful nerve test known as electromyography (EMG).
This test requires a separate referral to a neurologist and can take weeks (or yikes, even months) to schedule. An EMG measures the electrical currents of your nerves to determine if you have a nerve compression syndrome.
But this is where things get interesting.
Over the last 20 years, the field of ultrasound diagnosis for carpal and cubital tunnel has exploded. With these technological and research advances, we can now diagnose these peripheral nerve compressions with as good or nearly as good accuracy as the painful EMG alternative.
For the first time, this potential is becoming a reality.
Visit a hand surgeon, receive a referral to a neurologist, wait to schedule an EMG with neurology, show up and pay for a nerve test, and then re-schedule with your hand surgeon to review the results? Or undergo a painless ultrasound imaging test with your hand surgeon for immediate diagnosis?
Which one would you pick?
As I said before. Delivering both value and speed to the patient experience.
Ultrasound and orthopedic injuries
While ultrasound is not universally applicable to injuries of the upper extremity (it is not ideal for imaging broken bones, for instance), there are some tendon, ligament, and infectious conditions of the upper extremity that are well-suited for ultrasound diagnosis.
Depending on the clinical situation, this can include tennis elbow (lateral epicondylitis), tendon lacerations, hand ligament injuries, or conditions of the flexor pulley system. In the right setting, this technology can obviate the need for expensive and time-intensive send-away tests like MRI or CT scans.
Ultrasound-guided injections
The last big category of ultrasound use in the upper extremity is that of ultrasound-guided injections.
While some injections do not require a perfect degree of accuracy (trigger finger injections [1], for instance), there are others where the therapeutic effect can suffer if the injection is off by even a few millimeters (thumb CMC arthritis [2]).
In these latter injections, the option to image-guide the procedure is of tremendous value, both to the patient and the physician.
More pain relief is never a bad thing!
4. Ultrasound has limited downside
As with all technologies, there are of course limitations.
The biggest one, as mentioned above, is there are still many conditions we see that are not right for ultrasound use. These include broken bones, larger injuries of deep structures such as the shoulder, and the diagnostic evaluation of arthritis.
Another limitation, frankly, is the learning curve for the doctors. This bedside ultrasound technology is a newer development, and we are all actively working through training to use it more and more effectively.
While there may be some conditions best evaluated by a full-time radiologist, the list of applications for ultrasound in the hand clinic will only continue to expand.
Conclusion
Healthcare in the US is becoming more difficult to schedule and more expensive with each passing year. The recent improvements in handheld ultrasound give us a high-value, immediate-result tool to combat these forces and deliver better care for you.
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