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MSU basic teaching slide, esp for rheumatologist
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Basic musculoskeletal ultrasound abnormalities: definitions and appearance
Dr. Kai-Len Tsai M.D
Attending Physician, Taipei Medical University Hospital
Learning Objective
• To detect, assess and score synovial, tenosynovial
and entheseal inflammatory activity
• To detect, assess and score structural joint
damage(i.e. bone, tendons, cartilage
outline
1. Joint effusion
2. Synovial hypertrophy,
3. Tenosynovitis,
4. Enthesopathy, enthesitis,
5. Bursitis,
6. Bone abnormalities,
7. Cartilage lesions
1. Joint effusion 關節積液
• Synovial Fluid
• Abnormal hypoechoic or anechoic (relative to
subdermal fat, but sometimes may be isoechoic or
hyperechoic) intraarticular material that is
displaceable and compressible, but does not exhibit
Doppler signals
Anechoic 無回音
Hypoechoic 低回音
Isoechoic 同回音
Hyperechoic 高回音
膝關節 Knee
髖關節 HIP joint
肩關節 shoulder 肩唇
蹠骨關節 MTP joint
腕關節 Wrist joint
肘關節 Elbow 踝關節Ankle joint
Joint effusion
關節積液
A small quantity of fluid can be
present in the normal
joint (arrow). Long-axis view of the 2nd PIP joint flexor aspect.
dorsal osteophytes of PIP joint
Grey scale scoring of joint effusion and synovial hypertrophy
• Semi-quantitative scoring system
• Grade 0: No effusion
• Grade 1: Minimal amount of joint effusion
• Grade 2: Moderate amount of joint effusion[little
distension of the joint capsule]
• Grade 3: Extensive amount of joint effusion[with
high distension of the joint capsule]
J Rheumatol. 2005 Dec;32(12):2485-7.
Grade 1Grade 0
Grade 2Grade 3
Joint effusion grading
2. Synovial hypertrophy滑膜增生
• Abnormal hypoechoic (relative to subdermal fat, but
sometimes may be isoechoic or hyperechoic)
intraarticular tissue that is non-displaceable and
poorly compressible and which may exhibit Doppler
signals
腕關節 Wrist joint
踝關節 Ankle joint
膝關節 Knee joint 蹠骨關節 MTP joint
Synovial hypertrophy &Doppler ultrasonography
• Doppler ultrasonography:
• Is able to visualize blood flow by the change in frequency of sound waves reflected by moving objects(termed the Doppler shift), such as the cells inside blood vessels)
• CDUS technique is affected by the direction of blood flow, whereas the images obtained by PDUS are not direction-coded(able to detect a very slow blood flow rate, which is typical for inflamed joints and tendon areas is patients with RA
Active or inactive
• In the detection of highly vascularized pannus tissue,
which indicates active inflamed joints and tendons,
and furthermore, in the differentiation of active and
inactive RA.
Scoring system
• Inflammatory or active synovial hypertorphy(greyscale scoring)
• Grade 0 :No hypoechoic synovial thickening
• Grade 1 :Minimal hypoechoic synovial thickening(filling the angle between the periarticular bones, without bulging over the line linking tops of the bones)
• Grade 2 : Hypoechoic synovial thickening bulging over the line linking tops of the periarticular bones but without extension along the bone diaphysis
• Grade 4 : Hypoechoic synovial thickening bulging over the line linking tops of the periarticular bones and with extension to at least one of the bone diaphses
GSUS semiquantitatively
3 . Severe synovitis. 2 . moderate,
1 . mild, 0 . absence,
Grade 1 describes a small hypoechoic/anechoic line
beneath the joint capsule.
Grade 3 characterizes a strong
distension of the joint capsule
Grade 2, the joint capsule is
elevated parallel to the joint area.
掌指關節 MCP joint
腕關節 Wrist
掌指關節,腹面
OMERACT-EULAR PDUS composite scoring of synovitis
• Grade 0 (normal) : no synovial hypertrophy, no Doppler signals
• Grade 1 : minimal synovitis, minimal synovial hypertrophy, with (or without) no more than grade 1 Doppler signal
• Grade 2: moderate synovitis• Moderate synovial hypertrophy with or without no more than
grade 2 Doppler signal
• Minimal synovial hypertrophy and grade 2 Doppler signals
• Grade 3: Severe synovitis• Severe synovial hypertrophy with or without Doppler signal
• Minimal/moderate synovial hypertrophy and grade 3 Doppler signal
掌指關節 MCP joint
請問現在您區分出關節積水和滑膜增生的區域嗎?
*
請問您對這關節的power Doppler
signals 評幾分?
Grading?
3. Tendon lesions 肌腱
• Tenosynovitis 肌腱滑膜炎
• hypoechoic or anechoic synovial sheath widening or
thickening(effusion),
• tendon thickness
• peritendinous ± intra-tendinous PD or CD Doppler
signal
• Tendinitis 肌腱炎
• Tendon rupture
Normal biceps tendonTarget sign
Tenosynovitis (RA patient)
Tenosynovitis (Gouty arthritis)
Ankle joint lateral view
Peroneal tendon tenosynovitis
A RA patient
Trigger finger
Tendinitis (Achilles tendon,沒有sheath!
Tenosynovitis
Tendinitis
Achilles tendon
Ankylosing spondylitis
Calcification tendinitis
Tenosynovitis scoring
• Scoring Doppler in tenosynovitis
• Grade 0 : No peri-tendinous signals
• Grade 1 : Focal pen-tendinous signals
• Grade 2 : Multifocal peri-teninous signals
• Grade 3 : Diffuse peri-tendinous signals
4. Enthesopathy, enthesitis著骨點病變,附骨點病變
• Abnormally hypoechoic (loss of normal fibrillar
architectur) and/or thickened tendon or ligament at
its bony attachment (may occasionally contain
hyperechoic foci consistent with calcification), seen
in 2 perpendicular planes that may exhibit Doppler
signals and /or bony changes, including
enthesophytes, erosion, or irregularity)
Achilles tendon
These two pictures are both belonging to one AS patient
with left heel pain. Which is left one?
Knee deep infrapatellar bursa
5. Bursitis 滑囊炎Bursitis is the inflammation of one or more
bursae (small sacs) of synovial fluid in the body.
1. Shoulder bursa
• subacromnal-subdeltoid bursa: At ultrasound it appears as a very thin uniform, 1to 2 mm hypoechoic layer of synovial fluid surrounded by hyperchoic bursal wall and peribursal fat layers.
• Abnormal distention of the SASD bursa may appear anechoic or hypoechoic from simple fluid, or it may range from hypoechoic to hyperechoic as a result of complex fluid or synovial hypertrophy.
Supraspinatus tendon
Subdeltoid bursa
Subdeltoid bursitis
normal
類風濕結節 not bursa !
Gouty arthritis patient
Olecranon bursa
hemorrhagic bursitis of great trochanter
Patellar bone
Patellar bonenormal
Knee bursa
Baker’s cyst
Baker’s cyst rupture
6. Bone abnormalities
• Bone erosion
• An intra-articular discontinuity of the bone surface that
is visible in 2 perpendicular phanes
• Osteophytes
• Cortical protrusion seen in two planes
Semiquantitative scoring system of bone erosion
• metacarpophalangeal (MCP) joints
• normal: <2 mm;
• small erosion: 2 mm;
• moderate erosion: >2–<4 mm;
• large erosion: ≥4 mm.
Scoring erosion• 2nd MCP joint dorsal views
• 0: no ersion
• 1: <1mm
• 2: 1~2mm
• 3: 2~4mm
• 4: >4 mm
Rheumatology 2004;43:829–838
Bone erosion
normal
Osteophyte
7. Cartilage lesions
• Cartilage pathology
• Thining
• Loss of hypo-eccogenisity
• Total disappearance
• Crystal disease
• Double contour sign
• Intracartilage calcification
normal
Not double contour sign
double contour signCrystal disease
Double contour sign
Intracartilage calcification
Rheumatology (Oxford) July 1, 2007 vol. 46 no. 7 1116-1121
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