Synovial Osteochondrosis Doppler

Cure Arthritis Naturally

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a

Psoriatic arthritis. Sausage finger. Proximal interphalangeal joint. Volar transverse (a) and longitudinal (b) scans showing both tendon sheath and joint cavity widening. mp = middle phalanx; pp = proximal phalanx; t = flexor tendons;* = synovial fluid

Psoriatic Arthritis Achilles Ultrasound
Fig. 5.24 a, b

Psoriatic arthritis. Peritendinitis of the Achilles tendon (t). Longitudinal (a) and transverse (b) scans showing thickened hypo-ane-choic peritenon (arrowheads) with hypoechogenicity of the peritendinous soft tissues (*)

Psoriatic arthritis. Achilles tendon (f). Erosive enthesitis. Longitudinal (a) and transverse (b) scans showing power Doppler signal within the calcaneal bone erosions. c = calcaneal bone

US can detect changes in fascial thickness, and in the peri-fascial adipose tissue which becomes hypoechogenic with a characteristic 'muff-like' appearance best seen on transverse scans.

Ultrasound examination of patients with hyper-algesic fascia is particularly useful during treatment when correct positioning of the needle to deliver local therapy can be confirmed.

Psoriatic involvement of the distal interpha-langeal joints can be demonstrated with ultrasonography and features include joint space widening mainly on the longitudinal dorsal scan. The longitudinal volar scan confirms joint space widening together with any flexor tendon involvement which can be prominent.

The conformation and anatomical location of the crystal aggregates in pyrophosphate arthropa-thy are the main elements which help distinguish them from other crystalline arthropathies. The ability of ultrasonography to detect pyrophosphate crystals in joints with aspirated synovial fluid containing pyrophosphate crystals has been investigated with excellent results. Similar work has yet to be done in the setting of gout. The ease with which even minimal crystalline aggregates in pyrophosphate arthropathy and gout are visualized make ultrasonography a very promising tool to aid diagnosis. This is particularly pertinent in

5.4 Crystal-related arthropathies

Crystal-related arthropathies are a group of disorders in which minerals are deposited in musculoskeletal tissues, resulting in further pathological changes.

Both monosodium urate and calcium pyrophosphate dihydrate crystal aggregates can be clearly seen by ultrasonography in different anatomical areas and tissues. The spectrum of sonographic appearance of monosodium urate aggregation can vary from homogeneously punctuate (urate sand) to sharply defined hyperechoic densities of variable dimensions and eventually to dense topha-ceous material that is impermeable to the ultrasound beam (Fig. 5.26).

Snowstorm Appearance Ultrasound Gout
Gout of the first metatarsophalangeal joint.Transverse lateral view depicting "urate sand" mt = metatarsal head

the setting of acute inflammatory arthritis when other imaging modalities may be negative or unavailable. Future research into crystalline arthropathies should employ US, particularly to investigate the link between pyrophosphate arthropathy and osteoarthritis and in the potential monitoring of therapy for gout.

Gout

In patients with acute gout, US examination of the first metatarsophalangeal joint reveals joint space widening due to the presence of variable amounts of fluid and within it monosodium urate crystals, which appear as irregular floating echoic spots (Fig. 5.27) [1,46].

Tophaceous gout. Longitudinal dorsal US scan of the first metatarsophalangeal joint showing "soft"tophus"(arrowhead). The echotexture has an inhomogeneously echoic background with hyperechoic densities that do not generate posterior acoustic shadows. mt = metatarsal head; pp = proximal phalanx; t = extensor tendon

Fluid collections in patients with acute episodes of gout can show different sonographic patterns, ranging from homogeneous anechogenicity of the synovial fluid to aggregates of variable shape and echogenicity. Following sono-palpation (gentle pressure applied by the probe to the skin surface) of the joint being examined, these aggregates can be seen to float within the joint cavity giving rise to a 'snow-storm' appearance.

Tophaceous deposits may show a differing degree of reflectivity according to the level of compaction of the deposits. These vary from soft tophi, with typically varying echogenicity that are soft to palpation, to hard tophi that contain monosodium urate deposits generating a hyperechoic band and acoustic shadow and which are harder in consistency to palpation (Fig. 5.28) [19].

Intra-articular bone erosions frequently occur in patients with chronic gout. They are in some ways similar to those seen in rheumatoid arthritis, but tend to be deeper and more destructive. Extra-articular interruption of the bone profile due to intra-osseous tophi is easily detectable when the tophus is less compact and permits the passage of the ultrasound beam onto the bone surface.

The deposition of monosodium urate crystals within tendons can be variable depending on the size of the aggregates and on disease duration [47]. Micro-deposits, which can be observed in asymptomatic patients, appear as predominantly ovoid shaped hyperechoic densities.

These deposits maintain their high degree of reflectivity, even in situations where power and gain settings are minimized. The ensuing inflammatory response incited by these deposits generates a small hypoechoic 'halo' and sono-palpation of these areas can induce exquisite localized pain. The normal fibrillar echotexture of tendons can be

Ultrasound Gout And Crystals

Tophaceous gout. Longitudinal dorsal US scan of the first metatarsophalangeal joint showing "soft"tophus"(arrowhead). The echotexture has an inhomogeneously echoic background with hyperechoic densities that do not generate posterior acoustic shadows. mt = metatarsal head; pp = proximal phalanx; t = extensor tendon

Ultrasound Tophus

Tophaceous gout. Longitudinal dorsal US scan of the first metatarsophalangeal joint showing "hard" tophus.The bone profile of the joint cannot be visualized due to the presence of extensive urate deposition obstructing the path of the US beam. mt = metatarsal head; pp = proximal phalanx; t = extensor tendon

Tophaceous gout. Longitudinal dorsal US scan of the first metatarsophalangeal joint showing "hard" tophus.The bone profile of the joint cannot be visualized due to the presence of extensive urate deposition obstructing the path of the US beam. mt = metatarsal head; pp = proximal phalanx; t = extensor tendon completely deranged by the presence of intra-tendi-nous tophus formation, which appears as hypoe-choic material with the occasional presence of hyperechoic spots. Long-standing intra-tendinous tophus appears as hyperechoic bands that may generate an acoustic shadow according to their size and density.

Pyrophosphate arthropathy

Crystalline deposits in pyrophosphate arthropathy within hyaline and/or meniscal cartilage appear as a homogenously echogenic band that in most cases does not generate a posterior acoustic shadow [48-51]. This generates the characteristic 'double bordered' appearance that is very similar to that seen on conventional X-ray (Fig. 5.29).

This phenomenon can be explained by the irregular distribution of the crystals along the cartilage surface, which makes it impossible for a homogenous barrier to echo transmission to form.

In patients with acute synovitis fine hypere-choic spots can be seen within the synovial fluid. These anomalies, which can be found almost exclusively in patients with chondrocalcinosis confirmed on synovial liquid microscopy, are assumed to represent pyrophosphate crystal aggregates.

The concentration and the dimensions of these aggregates may be particularly conspicuous in patients with dense and whitish synovial liquid (Fig. 5.30).

Echogenic aggregates are also seen in pyrophosphate arthropathy. These are typically uniformly rounded in shape, with a sharply-defined outer profile. They can be demonstrated in various anatomical areas including the knee and wrist joints, popliteal cysts and sub-deltoid bursae. Crystal aggregates should be distinguished from joint debris and proteinaceous material floating within

Osteochondrosis The Lunate Bone
Pyrophosphate arthropathy.Wrist joint.Longitudinal (a) and transverse (b) views. c X-ray.Calcification of the triangular ligament of the carpus (arrowheads). t = extensor ulnaris carpi tendon; u = ulna; tr = triquetrum
Pyrophosphate Arthropathy WristThe Wrist Bone Calcium Buildup

Pyrophosphate arthropathy. Dorsal (a) and volar (b) longitudinal views of the wrist reveal large crystal deposits (arrowheads). c X-ray. ca = capitate bone; lu = lunate bone; ra = radius

Osteochondrosis The Lunate Bone

the joint cavity by demonstrating the reflectivity of the crystals present through adjustment of the ultrasound setting to a low level of power and gain.

Calcification of tendons in pyrophosphate arthropathy is typically linear, extensive and may generate an acoustic shadow. They must be distinguished from apatite deposits which are generally more discreet and nummular in conformation.

Apatite deposition disease

Calcific periarthritis is the main apatite-related condition. Calcium deposits are clearly detected because of their high reflectivity and generation of an acoustic shadow. Calcium deposits are, however, not always associated with posterior acoustic shadow and are connected to the degree of com paction of the crystalline aggregates (Fig. 5.31). Slurry calcifications have a nearly liquid consistency and can be aspirated. Their size, shape and location can vary significantly. In patients with acute inflammatory symptoms soft tissues surrounding the calcium deposits may show a hypoe-choic pattern due to edema. Increased power Doppler signal is a frequent finding. In clinically asymptomatic patients, single or multiple calcifications can often be observed.

With the dawn of US, there has been a significant upturn in the diagnosis of'painful shoulder' [52-56]. US examination accurately documents the anatomical target of the variants of peri-arthropathy.

In tenosynovitis of the long head of the biceps tendon, the most characteristic US finding is distension of the tendon sheath (Fig. 5.32).

Fascia Iliaca Block Nysora
Fig. 5.31 a, b

Apatite deposition disease of the shoulder. Longitudinal scan (a, b) of the supraspinatus tendon. Intratendinous calcification without (a) and with (b) posterior acoustic shadow (arrowhead). d = deltoid; h = humerus

Apatite deposition disease of the shoulder. Longitudinal scan (a, b) of the supraspinatus tendon. Intratendinous calcification without (a) and with (b) posterior acoustic shadow (arrowhead). d = deltoid; h = humerus

Tmj Joint Ultrasound

Exudative tenosynovitis in shoulder pain.Transverse (a) and longitudinal (b) anterior scans at the bicipital groove. Mild anechoic tendon sheath widening (*). h = humerus; t = long biceps tendon; d = deltoid

Exudative tenosynovitis in shoulder pain.Transverse (a) and longitudinal (b) anterior scans at the bicipital groove. Mild anechoic tendon sheath widening (*). h = humerus; t = long biceps tendon; d = deltoid

In lesions of the rotator cuff, US makes it possible to document a wide range of changes, which include thinning of the supraspinatus tendon, deposition of hydroxyapatite crystal aggregates and partial or complete tendon tears (Fig. 5.33) [55,56].

Subacromial-deltoid bursitis is fairly easily detected due to the generally conspicuous fluid collection that separates the walls. All patients with acute 'painful shoulder' must be examined with US methodically given the possibility that there may be more than one anomaly within the same individual.

Bicipital Groove Anomalies

Shoulder pain in patient with partial rupture of the supraspina-tus tendon (f). Discontinuity of the tendon fibrils appearing as a hypoechoic area (*) with the same shape of the distal echo-free edge of the supraspinatus tendon (arrowhead). h = humerus; d = deltoid

Shoulder pain in patient with partial rupture of the supraspina-tus tendon (f). Discontinuity of the tendon fibrils appearing as a hypoechoic area (*) with the same shape of the distal echo-free edge of the supraspinatus tendon (arrowhead). h = humerus; d = deltoid

5.5 Metabolic diseases

Tendon involvement is a prominent feature in patients with type II familial hypercholesterolemia. US is useful in establishing the diagnosis of heterozygous familial hypercholesterolemia in subjects with high levels of cholesterol and with no

Fig.5.34

Chronic tendinopathy of the Achilles tendon (t) in a patient with heterozygous familial hypercholesterolemia. Longitudinal US scan showing irregular fusiform thickening of the tendon, loss of the normal fibrillar echotexture, multiple areas of hypoechogenicity due to lipid infiltration and retrocal-caneal bursitis. c = calcaneal bone;* = synovial fluid; + = synovial proliferation

Fig.5.34

Chronic tendinopathy of the Achilles tendon (t) in a patient with heterozygous familial hypercholesterolemia. Longitudinal US scan showing irregular fusiform thickening of the tendon, loss of the normal fibrillar echotexture, multiple areas of hypoechogenicity due to lipid infiltration and retrocal-caneal bursitis. c = calcaneal bone;* = synovial fluid; + = synovial proliferation clinically evident xanthomata [57]. Tendon xan-thomata appear as focal or confluent hypoechoic areas (Fig. 5.34).

The typical sonographic appearance of tendi-nosis is characterized by areas of altered echogenicity. Defects in tendon contour (blurring of the tendon margins) and loss of the normal fibrillar echo-texture are frequent findings in patients with chronic tendinitis, post-traumatic tendinopathy, and in patients with metabolic disorders. Detection of intratendinous alteration of the normal fibrillar structure may be an important diagnostic clue to the presence of low mechanical resistance. Lack of homogeneity of tendon structure may range from focal aspects of fibrillar interruption to diffuse blurring of the tendon texture.

Intratendinous calcification is a frequent finding in patients with chronic inflammatory or degenerative tendinopathy and is frequently associated with endocrine and metabolic diseases (diabetes melli-tus and familial hypercholesterolemia) (Fig. 5.35).

Calcific tendinopathy of the Achilles tendon (t). Longitudinal (a) and transverse (b) scans showing an intratendinous hypere-choic line (arrowheads) generating an acoustic shadow.c = calcaneal bone

5.6 Connective tissue diseases

Systemic lupus erythematosus

Synovitis is a frequent early finding in patients with systemic lupus erythematosus. Fluid collection with consequent joint cavity widening and increased power Doppler signal is the most characteristic sonographic feature [58]. Unlike rheumatoid arthritis, the ensuing synovitis is not characterized by the presence of bone erosions. Spontaneous or treatment-induced short term changes in US appearance of arthritis are frequently observed.

Systemic sclerosis

Very high frequency US probes (> 20 MHz) make it possible to study skin and subcutaneous involvement in patients with systemic sclerosis [59]. At present, US is showing great promise in this area of rheumatology. US findings in systemic sclerosis include soft tissue calcification and narrowing of the distance between phalangeal apex and skin surface at the distal phalanx (Fig. 5.36). Moreover, color and power Doppler may play a valuable role in the assessment of blood perfusion.

Tumoral Calcinosis Finger

Calcinosis in systemic sclerosis. Longitudinal volar scan of the tip of the finger. arrowheads = calcification; dp = distal phalanx

Calcinosis in systemic sclerosis. Longitudinal volar scan of the tip of the finger. arrowheads = calcification; dp = distal phalanx

5.7 Synovial osteochondromatosis

Primary synovial osteochondromatosis is an idiopathic metaplasia of the synovium, and may involve any synovial joint. This tumor-like condition is usually monoarticular and is rarely polyarticular. The disease is characterized by the presence of meta-plastic chondroid islands confined to intrasynovial regions. Later on, cartilaginous foci spread and finally become calcified. Detachment of some calcified lobules gives rise to intra-articular loose bodies of various sizes. The affected joints do not appear inflamed; however, joint effusion may be occasionally present. The condition progresses slowly and can lead to secondary erosive and arthritic changes of joint bones.

The US appearance of synovial osteochondromatosis is characterized by numerous small echogenic foci. Most of these are associated with distal acoustic shadowing, corresponding to the conglomeration of calcified chondroid islands [16]. The synovium may be thickened.

US can suggest the presence of synovial osteo-chondromatosis, but is not definetively diagnostic. Therefore, conventional radiography is usually required to confirm the suspected diagnosis (Fig. 5.37).

Release of intra-articular loose bodies is not frequent. They appear as single or multiple echogenic foci with posterior acoustic shadowing, free-floating in the articular cavity when an effusion is present.

Power Doppler Joint

Synovial osteochondromatosis of the elbow.a Longitudinal US scan of the anterior aspect of the elbow showing bulge and thickening of the capsular profile (empty white arrowheads). Multiple echogenic foci with posterior acoustic shadowing (*) lining synovial profile are evident. b Frontal radiograph in same patient showing several rounded opacities (empty black arrow-heads),corresponding to calcified chondroid islands

5.8 Pigmented villonodular synovitis

Pigmented villonodular synovitis is a slow growing, benign synovial proliferative disorder that affects joints, bursae and tendon sheaths. Its etiology is controversial. The disease can present in three forms. First, the most common presentation affects the tendon sheaths - the so called giant cell tumor of the tendon sheaths - that appear as nodular tenosynovitis. It commonly occurs in the hands but has been identified in the foot as well. The typical feature in this form is the appearance of a painless mass on the finger. The other two forms of appearance are the localized form (nodular) and the diffuse form [60], which can be characterized by bursal and joint involvement. The disease is usually monoarticular and most commonly affects the knee, both in localized and diffuse presentation.

Initially, patients usually present with symptoms of mild discomfort and associated stiffness of the involved joint. Later on, pain and joint swelling may be evident.

The presenting US pattern in villonodular synovitis is non-specific. It usually appears as hyper-trophied synovium, thickened and nodular, and relatively homogeneously hypoechoic. Power Doppler US demonstrates increased flow within the mass [61]. Tenosynovial involvement by the giant cell tumor most commonly appears as single hypoechoic nodule [16], which tends to surround and dislocate the tendons (Fig. 5.38).

This pathological condition, both in the articular and extra-articular form, may be associated with blood-stained effusion.

Later on, the synovial nodule can erode the adjacent bone.

Giant cell tumor of the hand.Transverse US scan of the palmar surface of the finger demonstrates a solid, relatively homogeneous hypoechoic mass (*), filling the tendon sheath.Ten-dons (T) are peripherally dislocated

5.9 Septic arthritis

Septic arthritis demonstrates great variability in US presentation, depending on patient age, etiological agent, evolutionary stage and affected joint. The US appearance can range from mild echogenic articular effusion to joint destruction (Fig. 5.39).

Tibio-talar septic arthritis. Joint effusion appears inhomoge-neously echogenic with turbid and sand-like appearance (*) suggestive of septic fluid collection. ti = tibia; ta = talus

When the diagnosis of septic arthritis is presumed, US may be mostly beneficial not only for a diagnostic confirmation, but also for therapeutic intervention. In fact, sonography is clearly highly sensitive in detecting joint effusions and may also guide a careful arthrocentesis, allowing drainage of minimal amounts of deep-seated septic fluid.

In infants and children particularly, septic arthritis can have potentially serious consequences and is considered a medical emergency. Prompt diagnosis is of paramount importance to avoid a disastrous outcome, which can lead to joint destruction when the therapy is delayed or inadequate.

Septic arthritis is relatively frequent in infancy, most commonly involving the hip joint. A classic presentation of septic arthritis is a sudden onset of the pain and joint discomfort, and the presence of clinical parameters proposed by Kocher (fever

> 37.5°; erythrocyte sedimentation rate (ESR)

> 40mm/hr; increase in serum white blood cell (WBC) count > 12.000/mm3). None of these are highly sensitive or specific for septic arthritis. Septic arthritis must always be excluded even in situations where the clinical presentation is atypical. In this way, US plays a primary role in differential diagnosis.

The US hallmarks of septic arthritis are articular effusion with inhomogeneous echogenicity, synovial thickening, and frequently synovial hyper-vascularity upon power Doppler US [62]. At the first evaluation, bone erosion may already be visualized (Fig. 5.40).

Transient synovitis in children can mimic septic arthritics. US examination shows evidence of joint effusion, which generally appears anechoic and homogeneous [63]. The synovium is usually thickened without hypervascularity at power Doppler evaluation. Bony irregularities are typically absent (Fig. 5.41).

We must remember that septic arthritis is a great mimic. Polyarticular involvement is very uncommon in septic arthritis [64]. On the contrary, even if the echographic evaluation reveals a monoarticular and homogeneously anechoic effusion, and a synovial thickening without hypervas-cularity, arthrocentesis is still mandatory if the clinical and laboratory results evoke septic involvement [62].

Wcc Joint Effusion Septic

Tibio-talar septic arthritis. Joint effusion appears inhomoge-neously echogenic with turbid and sand-like appearance (*) suggestive of septic fluid collection. ti = tibia; ta = talus

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