RadioGraphics
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
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 Angtuaco, T. L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Angtuaco, T. L.
Related Collections
Right arrowRelated Article
RadioGraphics 2006;26:830-831

EDUCATION EXHIBIT

Invited Commentary

Teresita L. Angtuaco, MD

Department of Radiology, University of Arkansas for Medical Sciences Little Rock, Arkansas

Obstetric ultrasonography (US) can vary in complexity, depending on the stage of gestation. A complete obstetric US examination performed in the second or third trimester requires the documentation of specific fetal anatomic structures. Discipline and expertise are needed to obtain images that allow the comparison of these landmarks from one examination to another. A comprehensive US survey is reported to be highly accurate for the detection of fetal abnormalities (1,2). The need to define what constitutes a complete obstetric US examination prompted the American College of Radiology and the American Institute of Ultrasound in Medicine to issue practice guidelines. These guidelines can be accessed through the organizational Web sites, at http://www.acr.org (quality and patient safety section) and http://www.aium.org/publications/clinical/obstetrical.pdf. Among the requirements outlined in these guidelines is the documentation of the presence of the fetal extremities. This minimum requirement applies to all second- and third-trimester examinations, regardless of the indication. In most US clinics, common indications for obstetric US include estimation of fetal age, vaginal bleeding, and discrepancy between fetal size and estimated gestational age according to menstrual history. However, when an examination is requested specifically to seek a fetal anomaly, the level of expertise and the requirements of the examination change. Such a request may be precipitated by family history, abnormal results of a serum screening test, or an abnormality seen at a prior US examination. The routine examination is then converted to a targeted obstetric US examination in which a more intensive search for chromosomal markers is performed.

A targeted fetal musculoskeletal US examination begins with the routine demonstration of all four extremities. In skeletal dysplasias manifested by bone shortening, it is mandatory to measure the humerus, femur, tibia, and radius, at a minimum. Measurements of the ulna and fibula may be added as needed to help narrow the diagnosis to the micromelic, rhizomelic, or mesomelic type of skeletal dysplasias. Although measurements of the bones of the fetal hands have been published (3), such measurements are not routinely obtained. Instead, the hands are imaged to look for typical features that may be suggestive of a chromosomal anomaly (4–7). The search is especially important when other chromosomal markers have been detected in the brain, chest, or abdomen. When diminished fetal motion is suspected, spontaneous movements of the fetal hands also can be assessed (8). In these instances, a thorough knowledge of hand abnormalities is essential. In diagnostic clinics that do not encounter fetal anomalies frequently, there is a tendency to send patients to a tertiary referral center that has more experience in dealing with these cases. When such a referral is not possible or not easily achievable, the radiologist is left with the task of interpreting the US findings and deriving a differential diagnosis. Among the conditions that are strongly associated with hand anomalies, trisomy 18 tops the list (9–12). Short digits also have been reported in Down syndrome (13,14), as has polydactyly in trisomy 13 (15).

The main objection to performing a detailed evaluation of the fetal hands is that it is too time-and labor-intensive (16). It is true that it takes a certain level of expertise and experience to obtain a clear view of a specific hand abnormality. It could be quite frustrating, trying to capture an image of a very mobile upper extremity, especially in the presence of polyhydramnios, which may be associated with musculoskeletal abnormalities. With the increasing interest in three-dimensional imaging, the fetal extremities have been among the first targets for showing the advantages of three-dimensional over two-dimensional US. Surface rendering algorithms have helped provide exquisitely detailed images of the whole hand and wrist, adding another dimension to the documentation of anomalies (17–21).

The article by Rypens, Dubois, Garel, Four-net, Michaud, and Grignon in this issue of RadioGraphics provides a concise summary of fetal hand abnormalities that can be detected with US. Publications that deal with hand abnormalities are definitely in the minority when compared with those about other fetal anomalies, and it is refreshing to see a concise review article on the subject. Rypens and colleagues effectively classify fetal hand anomalies into six groups, thereby providing a framework on which further characterization may be based. Although the sonologist may still need to consult the literature for further details about a specific hand anomaly (22–27), this article serves as a good starting point for general reference. The brief treatment of each major category of anomaly is accompanied by excellent figures that reinforce the verbal definition or description of that category and leave a lasting impression in the reader’s mind. Every radiologist who performs obstetric US can benefit greatly from this review of the US features of hand anomalies that may be observed during routine fetal evaluations.


   References
Top
 References
 

  1. Yeo L, Guzman ER, Shen-Schwarz S, et al. Value of a complete sonographic survey in detecting fetal abnormalities: correlation with perinatal autopsy. J Ultrasound Med 2002;21(5):501–510.[Abstract/Free Full Text]
  2. Stewart TL. Screening for aneuploidy: the genetic sonogram. Obstet Gynecol Clin North Am 2004; 31(1):21–33.[CrossRef][Medline]
  3. Tovbin J, Maymon R, Tovbin L, et al. Prenatal age-specific reference intervals for measuring all five digits of the fetal hand. Ultrasound Obstet Gynecol 2002;19(6):583–587.[CrossRef][Medline]
  4. Bromley B, Benacerraf B. Abnormalities of the hands and feet in the fetus: sonographic findings. AJR Am J Roentgenol 1995;165(5):1239–1243.[Abstract/Free Full Text]
  5. Bronshtein M, Stahl S, Zimmer EZ. Transvaginal sonographic diagnosis of fetal finger abnormalities in early gestation. J Ultrasound Med 1995;14(8): 591–595.[Abstract]
  6. Paluda SM, Comstock CH, Kirk JS, et al. The significance of ultrasonographically diagnosed fetal wrist position anomalies. Am J Obstet Gynecol 1996;174(6):1834–1837.[CrossRef][Medline]
  7. Bromley B, Shipp TD, Benacerraf B. Isolated polydactyly: prenatal diagnosis and perinatal outcome. Prenat Diagn 2000;20(11):905–908.[CrossRef][Medline]
  8. Sparling JW, Van Tol J, Chescheir NC. Fetal and neonatal hand movement. Phys Ther 1999;79(1): 24–39.[Abstract/Free Full Text]
  9. Bronsteen R, Lee W, Vettraino IM, et al. Second-trimester sonography and trisomy 18: the significance of isolated choroid plexus cysts after an examination that includes the fetal hands. J Ultrasound Med 2004;23(2):241–245.[Abstract/Free Full Text]
  10. Makrydimas G, Papanikolaou E, Paraskevaidis E, et al. Upper limb abnormalities as an isolated ultrasonographic finding in early detection of trisomy 18: a case report. Fetal Diagn Ther 2003; 18(6):401–403.[CrossRef][Medline]
  11. Yeo L, Guzman ER, Day-Salvatore D, et al. Prenatal detection of fetal trisomy 18 through abnormal sonographic features. J Ultrasound Med 2003; 22(6):581–590.[Abstract/Free Full Text]
  12. Quintero RA, Johnson MP, Mendoza G, et al. Ontogeny of clenched-hand development in trisomy 18 fetuses: a serial transabdominal fetoscopic observation. Fetal Diagn Ther 1999;14(2): 68–70.[CrossRef][Medline]
  13. Goldstein I, Gomez K, Copel JA. Fifth digit measurement in normal pregnancies: a potential sonographic sign of Down’s syndrome. Ultrasound Obstet Gynecol 1995;5(1):34–37.[CrossRef][Medline]
  14. Maymon R, Tovbin Y, Dreazen E, et al. All five digits of the hands of fetuses with Down syndrome are short. Ultrasound Obstet Gynecol 2004;23(6): 557–560.[CrossRef][Medline]
  15. Tongsong T, Sirichotiyakul S, Wanapirak C, et al. Sonographic features of trisomy 13 at midpregnancy. Int J Gynaecol Obstet 2002;76(2):143–148.[CrossRef][Medline]
  16. Reiss RE, Foy PM, Mendiratta V, et al. Ease and accuracy of evaluation of fetal hands during obstetrical ultrasonography: a prospective study. J Ultrasound Med 1995;14(11):813–820.[Abstract]
  17. Krakow D, Williams J 3rd, Poehl M, et al. Use of three-dimensional ultrasound imaging in the diagnosis of prenatal-onset skeletal dysplasias. Ultrasound Obstet Gynecol 2003;21(5):467–472.[CrossRef][Medline]
  18. Garjian KV, Pretorius DH, Budorick NE, et al. Fetal skeletal dysplasia: three-dimensional US—initial experience. Radiology 2000;214(3):717–723.[Abstract/Free Full Text]
  19. Ploeckinger-Ulm B, Ulm MR, Lee A, et al. Antenatal depiction of fetal digits with three-dimensional ultrasonography. Am J Obstet Gynecol 1996;175:571–574.[CrossRef][Medline]
  20. Hata T, Aoki S, Akiyama M, et al. Three-dimensional ultrasonographic assessment of fetal hands and feet. Ultrasound Obstet Gynecol 1998;12(4): 235–239.[CrossRef][Medline]
  21. Budorick NE, Pretorius DH, Johnson DD, et al. Three-dimensional ultrasound examination of the fetal hands: normal and abnormal. Ultrasound Obstet Gynecol 1998;12(4):227–234.[CrossRef][Medline]
  22. Witters I, Van Bokhoven H, Goossens A, et al. Split-hand/split-foot malformation with paternal mutation in the p63 gene. Prenat Diagn 2001; 21(13):1119–1122.[CrossRef][Medline]
  23. Witters I, Devriendt K, Moerman P, et al. Bilateral tibial agenesis with ectrodactyly (OMIM 119100): further evidence for autosomal recessive inheritance. Am J Med Genet 2001;104(3):209–213.[CrossRef][Medline]
  24. Leung KY, MacLachlan NA, Sepulveda W. Prenatal diagnosis of ectrodactyly: the ‘lobster claw’ anomaly. Ultrasound Obstet Gynecol 1995;6(6): 443–446.[CrossRef][Medline]
  25. Drapkin RI, Genest DR, Holmes LB, et al. Unilateral transverse arm defect with subterminal digital nubbins. Pediatr Dev Pathol 2003;6(4):348–354.[CrossRef][Medline]
  26. Boute O, Depret-Mosser S, Vinatier D, et al. Prenatal diagnosis of thrombocytopenia–absent radius syndrome. Fetal Diagn Ther 1996;11(3):224–230.[Medline]
  27. Tongsong T, Sirichotiyakul S, Chanprapaph P. Prenatal diagnosis of thrombocytopenia-absent radius (TAR) syndrome. Ultrasound Obstet Gynecol 2000;15(3):256–258.[CrossRef][Medline]

Related Article

Obstetric US: Watch the Fetal Hands
Françoise Rypens, Josée Dubois, Laurent Garel, Jean-Christophe Fournet, Jacques L. Michaud, and Andrée Grignon
RadioGraphics 2006 26: 811-829. [Abstract] [Full Text] [PDF]




This Article
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
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 Angtuaco, T. L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Angtuaco, T. L.
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOGRAPHICS RADIOLOGY RSNA JOURNALS ONLINE