US in diagnosis of rheumatic diseases BP Putra... · The role of ultrasound in diagnosis and...

The role of ultrasound

in diagnosis and treatment of rheumatic

diseases Focus on knee

dr.B.P.Putra Suryana SpPD-KR, FINASIM

Rheumatology Division, Department of Internal Medicine

Brawijaya University – Saiful Anwar Hospital, Malang

PIN PB PAPDIWorkshop on Basic Musculoskeletal Ultrasound

Surabaya 5-10-2019

Workshop Objective

1. To understand the role of US in

diagnosing rheumatism on knee

2. To understand the role of US in knee

injection

3. To practice performing standard view US

on normal knee

OUTLINE

• Technical issues

• Normal knee

• US findings in rheumatic diseases: Osteoarthritis

Gout

Pseudogout

Rheumatoid arthritis

Tendinosis

• Guidance for joint injection

Klinik Reumatik dan Osteoporosis Paviliun RS Saiful Anwar Malang

Bimbingan tindakan injeksi intra-artiuler

PPDS IPD FKUB – RSSA Malang

Equipment

Transducers

Linear 12-5 Mhz Curvilinear 9-4 Mhz Compact linear 15-7

Mhz

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Transducer positioning

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Transducer movements

Heel-toe maneuver Toggle maneuver

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Normal knee

Anterior (sagittal view)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Anterior (transversal view)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Anterior (pre-patellar)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Anterior (flexion)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Medial (coronal view)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Lateral (coronal view)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Posterior (transverse view)

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

US findings in rheumatism

Knee effusions

Suprapatellar bulging with positive patellar tap test on knee commonly

represent knee joint effusions

Knee joint effusion

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Knee joint swelling in OA patients

Slide collection from Rheumatology Division,

Saiful Anwar Hospital, Malang.

Slide collection from Rheumatology Divison, Saiful Anwar Hospital, Malang.

Intra-articular hemorrhage

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Osteophytes in knee OA

Osteophyte (spur formation) is a bony-enlargement commonly at joint

margin. It’s a typical findings in OA patients

Osteophytes

Jain M, Samuels J. Musculoskeletal Ultrasound in the Diagnosis of Rheumatic Disease. Bulletin of the NYU

Hospital for Joint Diseases 2010;68(3):183-90.

Joint cartilage damages

Cartilage damages are early pathologic process in OA

Joint cartilage disruption

Jain M, Samuels J. Musculoskeletal Ultrasound in the Diagnosis of Rheumatic Disease. Bulletin of the NYU

Hospital for Joint Diseases 2010;68(3):183-90.

Acute monoarthritis

Acute arthritis on knee may caused by gouty attack, possibility of septic

arthritis must be excluded.

Gout: double contour sign

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Diagnostic Test Value of Ultrasonography

Compared to Joint Effusion Crystal Analysis as Gold

Standard for Diagnosing Gouty Arthritis Dini Rahmawati1, Indrastuti Normahayu1, B.P.Putra Suryana2, Harun Al Rasyid3

1Radiological Departement dr. Saiful Anwar General Hospital, Malang 2Internal Medicine Division dr. Saiful Anwar General Hospital, Malang 3Laboratory of Public

Health Medical Faculty of Brawijaya University, Malang E-mail : rajaaisya@gmail.com

Slide collection from Rheumatology Division, Saiful Anwar Hospital, Malang.

2015 GOUT Classification

Criteria (ACR/EULAR)

Tophus in gout

Tophus is formed by uric acid crystals deposition around the joints surrounded by

inflammation area. Sometimes should be distinguished with other nodules.

Slide collection from Rheumatology Division,

Saiful Anwar Hospital, Malang.

Tophus: Hallo sign

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Pseudogout: chondrocalcinosis

Pseudo-gout is caused by calcium pyrophospate dihydrate (CPPD)

deposition within the joints causing inflammation and joint cartilage

calcification (chondrocalcinosis)

Pseudogout: chondrocalcinosis

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Baker cyst

Posterior swelling at knee joint in OA patients commonly caused by Baker

cyst.

Baker cyst: comma sign

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Leg swelling

Ruptured Baker cyst

DVT on calf

Leg swelling caused by ruptured Baker cyst clinically should be

distinguished with deep vein thrombosis on calf.

Ruptured Baker cyst

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Pre-patellar bursitis with effusion

Slide collection from Rheumatology Division, Saiful Anwar Hospital, Malang.

Prepatellar bursa

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Patellar tendon tendinosis

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Quadriceps tendinosis

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Joint erosions in RA

Joint erosions in RA patients are best identified on carpal bones, MCP and

PIP joints. Erosions in RA typically starts on joint margins.

Joint erosions on wrist

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

Pannus in RA

Pannus are proliferative synovium with cells

accumulation and high vascularisation within

the joint lead to develop joint erosions.

Synovial hypertrophy

Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.

US guidance for joint injection

In-plane and out-of-plane

Standoff positioning

US guided injection

Spinner DA et al (Eds). Atlas of ultrasound guided musculoskeletal injection. Springer,2014.

Lateral approach knee injection

Accuracy of knee injections

Spinner DA et al (Eds). Atlas of ultrasound guided musculoskeletal injection. Springer,2014.

6. Cunnington J, Marshall N, Hide G, et al. A randomized, doubleblind, controlled study of ultrasound-guided corticosteroid injection into the

joint of patients with infl ammatory arthritis. Arthritis Rheum. 2010;62(7):1862–9.

7. Bum Park Y, Ah Choi W, Kim YK, et al. Accuracy of blind versus ultrasound-guided suprapatellar bursal injection. J Clin Ultrasound.

2012;40(1):20–5.

8. Balint PV, Kane D, Hunter J, et al. Ultrasound guided versus conventional joint and soft tissue fl uid aspiration in rheumatology practice: a

pilot study. J Rheumatol. 2002;29(10):2209–13.

Pes anserine bursa injection

Transducer position with gel standoff over pes anserine bursa with in-

plane needle approach

Spinner DA et al (Eds). Atlas of ultrasound guided musculoskeletal injection. Springer,2014.

Baker’s cyst injection

Probe position over posterior knee with in-plane injection technique

Spinner DA et al (Eds). Atlas of ultrasound guided musculoskeletal injection. Springer,2014.

Take Home Message

Musculoskeletal ultrasound is a practical

procedure and useful in identifying joint

abnormalities to support diagnosis

confirmation and intervention in rheumatic

diseases.

Terima kasih dan semoga

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