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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 215a, b Subdeltoid bursitis in acute polyarthritis: effusion (arrows) with
separation of the deltoid muscle and rotator cuff, also bicipital tenosynovitis.
a Lateral longitudinal scan, b anterior transverse scan
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
a
Fig. 216a, b Chronic bursitis in a
patient with erosive shoulder arthritis
and a rotator cuff defect; echogenic
bursal contents. a Transverse scan,
b longitudinal scan
Tenosynovitis of the Long Biceps Tendon (Bicipital Tenosynovitis)
..............................................................................................................
n
Occurrence: a frequent accompaniment of degenerative or inflammatory joint
disease
n
Sonographic findings :
x
Typical circumferential, hypoechoic widening of the tendon sheath with a halo
or “fried egg” pattern in the anterior transverse scan (Fig.
on black asphalt” pattern is seen in the anterior longitudinal scan.
x
CDS shows increased vascularity in a primary inflammatory process (Fig. 218).
b
217). A “white stripe
167
6.13 Joint Pain and Swelling
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6
6
b
a
Fig. 217a, b Bicipital tenosynovitis in polyarthritis (anterior transverse and
longitudinal scans over the bicipital groove). a Transverse scan: halo pattern.
Principal Signs and Symptoms
Principal Signs and Symptoms
b Longitudinal scan: hypoechoic to anechoic widening of the tendon sheath
(arrows), central echogenic tendon (T)
ab
Fig. 218a, b Bicipital tenosynovitis in polyarthritis. Anterior transverse scan shows
an anechoic rim surrounding the echogenic biceps tendon, also numerous color
flow signals including small arterial signals
Fig. 219 Biceps tendon calcification in
polyarthritis: convex echogenic zone
within the biceps tendon sheath with a
distal acoustic shadow, indicating calcification
x
Anterior scan planes may yield significant additional findings (e.g., subdeltoid
bursitis or calcifications within the biceps tendon; Fig.
168
219).
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Arthritis of the Shoulder
..............................................................................................................
Occurrence: Shoulder involvement is common in the setting of primary inflamma-
tory rheumatic diseases.
n
Sonographic findings :
x
Shoulder arthritis (Fig. 220):
– Pericapital hypoechoic rim, teardrop-shaped expansion of the axillary recess
in the axillary scan
– Hypoechoic collections visible in anterior and posterior scans when copious
effusion is present
– Detection of erosive defects indicating a destructive rheumatoid joint
disease
– Frequent concomitant, nonspecific bicipital tenosynovitis or subdeltoid
bursitis
x
Erosive shoulder arthritis (Fig. 221):
– Shallow irregularities in the humeral head contours or deep circumscribed
defects (erosions), usually seen best in posterior and axillary scans
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6
Principal Signs and Symptoms
Principal Signs and Symptoms
ab
Fig. 220a, b Shoulder involvement in a patient with rheumatoid arthritis.
a B-mode image: small effusion in the articular recess (longitudinal axillary scan).
b CDS: longitudinal scan demonstrates axillary vascular structures (circumflex
humeral artery)
ab
Fig. 221a, b Erosive arthritis affecting both shoulder joints. a High-level echoes
from the base of a deep bony defect. b Irregular, fragmented bone echoes in the
arthritic left shoulder of a patient with ankylosing spondylitis
169
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
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6
6
– Typical lesion location at chondro-osseous boundaries
– Erosions can be distinguished from pseudoerosions by defining the echo-
genic base of the erosive defect.
n
Role of sonography: Ultrasound scanning can detect early inflammatory changes
in patients who have subtle or equivocal clinical findings. Erosive changes due to
pannus formation are typical in rheumatoid arthritis.
Fig. 222 Postinflammatory destruction
Principal Signs and Symptoms
Principal Signs and Symptoms
of the rotator cuff in an osteoarthritic
shoulder. Erosive defects appear along
the lateral circumference of the humeral
head (“battlement ” pattern), with
hypertrophy of the deltoid muscle
Secondary Osteoarthritis of the Shoulder
..............................................................................................................
n
Definition: extensive productive and erosive changes resulting from a chronic
inflammatory process
n
Sonographic findings :
x
Alternating bony excresences and erosions resembling the “battlements” on a
fortress wall (Fig.
x
Frequent complete destruction of the rotator cuff
Acromioclavicular and Sternoclavicular Arthritis
..............................................................................................................
n
Causes, occurrence :
x
Acromioclavicular arthritis may occur in the setting of rheumatoid arthritis
223).
(Fig.
x
Sternoclavicular arthritis may occur in patients with HLA-B27-associated spondylarthropathy (Fig.
n
Sonographic findings :
x
Convex hypoechoic or anechoic expansion of the joint capsule due to effusion in
the acromioclavicular joint
222)
224).
Fig. 223 Acromioclavicular arthritis in
a patient with acute polyarthritis:
inflammatory, hypoechoic thickening
of the acromioclavicular joint capsule.
170
A = acromion, C = clavicle
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 224a, b HLA-B27-positive spondylarthritis of the sternoclavicular joint.
a B-mode image: anechoic exudate (arrows). b CDS: inflammatory vascularization.
S = sternum, C = clavicle
x
Increased intra- or periarticular vascularity in the florid stage
x
Erosions may be found in long-standing cases.
Cubital Arthritis (Fig. 225)
..............................................................................................................
n
Definition: exudative or proliferative inflammation of the elbow joint in a setting
of rheumatoid arthritis or other disease.
n
Sonographic findings: anechoic effusions and hypoechoic synovitis, occurring
mainly in capsular recesses (olecranon fossa, radial fossa, coronoid fossa).
n
Scanning tips: Effusion can be dynamically provoked by flexing the elbow joint
30h (in anterior longitudinal scan).
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6
Principal Signs and Symptoms
Principal Signs and Symptoms
ab
Fig. 225a, b Cubital arthritis in a patient with a long history of rheumatoid
arthritis (anterior humeroradial longitudinal scan). a Hypoechoic synovitis.
b Posterior longitudinal scan of the olecranon fossa
Nodules in the Elbow Region
..............................................................................................................
Occurrence: Masses and subcutaneous nodules are commonly found on the back of
the elbow in patients with rheumatoid diseases.
n
Sonographic findings :
x
Fluid-filled areas (e.g., olecranon bursitis or ganglion)
x
Solid structures that appear homogeneously hypoechoic (e.g., rheumatoid
nodules, Fig.
226)
171
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
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6
6
ab
Fig. 226a, b Rheumatoid nodule: uniformly hypoechoic, noncompressible elliptical nodule. The patient presented clinically with arthralgia and strongly positive
rheumatoid factors. a Longitudinal scan, b transverse scan
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 227 Chronic gouty arthropathy:
hyperechoic structures in the soft tissues with a posterior acoustic shadow
(firm gouty nodules in the soft tissues
about the elbow)
x
Gouty tophi, which may contain high-level echoes with acoustic shadows or
posterior comet-tail artifacts (Fig.
Articular Synovitis of the Finger and Toe Joints
..............................................................................................................
n
Occurrence: in inflammatory rheumatic diseases. The small joints of the fingers
and toes tend to show early involvement, especially in rheumatoid arthritis.
n
Sonographic findings (Figs. 228 and 229):
x
Convex hypoechoic or anechoicanechoic expansion of the joint capsule
x
Small, anechoic exudate
x
Erosive lesions
n
Scanning tips :
x
Dynamic examination of the joints can accentuate subtle findings.
x
Always compare with adjacent and contralateral joints.
227)
ab
Fig. 228a–c Articular synovitis of
the metacarpophalangeal (MCP) joints.
a Exudative synovitis of the fourth MCP
joint in an acute episode of palindromic
rheumatism (transverse scan).
b Synovitis of the third MCP joint in
c
rheumatoid arthritis : small, teardrop-
shaped effusion below the flexor tendon
(volar longitudinal scan). c Normal appearance of the fourth MCP joint of the right
hand. T = flexor tendon
172
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 229a–c Articular synovitis of the
metatarsophalangeal (MTP) joint. a Erosive psoriatic arthritis; dorsal longitudinal scan over the first MTP joint shows
exudation and marked hypoechoic
expansion of the joint capsule with
smooth dorsal bony contours. b Same
patient: erosion detected by circumferential scanning. c Magnified view of b
c
shows a deep defect with typical highamplitude basal echoes
ab
Fig. 230a, b Longitudinal scan over the third MTP joint during an attack of gout in
a patient with gouty arthritis. a Hypoechoic expansion of the third MTP joint capsule of the right foot. b Marked increase in intra- and pericapsular vascularity
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Principal Signs and Symptoms
Principal Signs and Symptoms
x
With articular synovitis of the toes, ultrasound-guided percutaneous aspiration
may be helpful in the detection of urate crystals, for example (differential diagnosis: gouty arthritis, Fig.
n
Accuracy of sonographic diagnosis: Ultrasound has established itself as a very
sensitive modality for early diagnosis. Even mild erosions and synovitic changes
that are not yet detectable by physical examination (e.g., teardrop-shaped exudates) can be detected sonographically.
Arthritis of the Hip (Fig. 231)
..............................................................................................................
n
Sonographic findings: convex, hypoechoic area i 7 mm wide between the cortex
and joint capsule at the junction of the femoral head and neck. A difference of
i 2 mm between the right and left sides is abnormal.
n
Scanning tips :
x
If findings are equivocal, it may be possible to increase the distance between
the cortex and capsule by flexion.
x
Ultrasound-guided diagnostic aspiration may be required.
230).
173
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
ab
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 231a, b Arthritis of the right hip in a patient with (presumably yersiniareactive) spondylarthropathy. a Capsule of the right hip joint shows hypoechoic
widening to 12 mm. b Capsule of the left hip joint is normal (6 mm). Ten days
before, the patient presented with acute erythema nodosa; he presented now with
peracute groin and leg pain and high Yersinia titers
n
Role of sonography in patients with suspected arthritis of the hip:
x
Detection of synovitis : The anterior longitudinal scan can detect states of synovitic irritation with an increased intra-articular volume or effusion (convex
hypoechoic expansion of the joint capsule).
– Determine the distance between the femoral neck cortex and the echo of the
fibrous joint capsule (see Table
7, p. 45, for normal and abnormal values).
– Dynamic examination (slight flexion and rotation) can aid in the detection of
even small effusion volumes.
x
Ultrasound-guided joint aspiration: accurate determination of the site and direction of needle insertion prior to diagnostic or therapeutic arthrocentesis
n
Differential diagnosis: Synovitis requires differentiation from other intra- or peri-
articular causes of pain (e.g., abscess, bursitis, hematoma).
Arthritis of the Knee (Fig. 232)
..............................................................................................................
n
Sonographic findings :
x
Detection of hypoechoic effusion (exudative component) and echogenic villous
synovial hypertrophy (proliferative component), chiefly in the anterior recess
x
Detection of erosive changes consistent with arthritis (see Fig. 211), p. 163)
x
Possible formation of a posterior C-shaped or dumbbell-shaped popliteal cyst
n
Scanning tips :
x
Small amounts of exudate can be detected by active quadriceps contraction or
palpation by the examiner.
x
With diffuse echogenic thickening of the capsule, use CDS to detect vascularity
in the synovial villi.
n
Role of sonography in patients with suspected arthritis of the knee:
x
Detection of exudation: It is common for marked exudative or proliferative
synovitis to develop in the knee joint. Ultrasound can detect effusions in the
supra- and papapatellar recesses. Synovial thickening is easily detected
owing to the high impedance mismatch between the fluid effusion and the
synovium.
174
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 232a–c Pronounced exudative
arthritis of the knee with villous proliferation in a patient with spondylarthritis.
a Suprapatellar longitudinal scan.
b Suprapatellar transverse scan.
c CDS : echogenic synovial thickening
with associated vascularization
x
Detection of vascularity: Hypertrophic villous synovitis is a common finding in
many chronically arthritic knees. CDS can demonstrate peri- and intra-articular
vascularization (signs of rheumatic synovial hypertrophy). A semiquantitative
analysis can be done to assess the activity of the inflammation.
Osteoarthritis of the Knee
..............................................................................................................
n
Sonographic findings (see Fig. 211), p. 163):
x
Marginal osteophytes in the medial or lateral joint space
x
Concomitant effusion signifying an activated osteoarthritis
n
Scanning tip: Equivocal findings can be clarified by ultrasound-guided aspiration
and synovial fluid analysis.
Baker Cysts (Fig. 233)
..............................................................................................................
n
Definition: cystic outpouching of the synovium behind the knee
n
Occurrence: in various inflammatory or degenerative diseases of the knee joint
n
Clinical manifestations: Symptoms range from local pain to occasional acute epi-
sodes of severe, painful swelling of the calf and lower leg (differential diagnosis :
below-knee deep venous thrombosis).
n
Sonographic findings: The cyst appears in transverse section as a typical C-shaped
or dumbbell-shaped mass bordering the gastrocnemius muscle. Generally it has a
visible communication with the posterior joint space of the knee.
n
Accuracy of sonographic diagnosis: In the typical case of an anechoic cystic mass,
a typical Baker cyst can be quickly identified owing to the large impedance difference relative to the surrounding echogenic soft tissues (see Fig.
c
234).
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Principal Signs and Symptoms
Principal Signs and Symptoms
175
6.13 Joint Pain and Swelling
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
ab
Fig. 233a, b Baker cyst appears as an elongated, tubular, almost anechoic mass.
Principal Signs and Symptoms
Principal Signs and Symptoms
a Transverse scan, b longitudinal scan
Fig. 234 Echogenic Baker cyst of the
calf. A Baker cyst containing echogenic
material extends some distance along
the musculotendinous compartments of
the lower leg. The patient presented
clinically with chronic calf pain. A history
of heavy smoking raised initial suspicion
of peripheral arterial occlusive disease
(PAOD), but vascular studies were nor-
mal. The symptoms resolved after cyst
resection
Arthritis of the Ankle Joint (Fig. 235)
..............................................................................................................
n
Sonographic findings :
x
Convex expansion of the anterior joint space between the tibia and talus
x
The posterior joint space may show a tibiotalar effusion or synovitis.
x
These findings are often accompanied by medial and lateral flexor tenosynovitis.
ab
Fig. 235a, b Arthritis of the ankle joint: marked, hypoechoic expansion of the
tibiotalar joint. a Longitudinal scan, b transverse scan
176