PIN XIV PB PAPDI

Workshop on Basic Musculoskeletal Ultrasound

Makassar, 14 Oktober 2017

The role of ultrasound

in diagnosis 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
 OUTLINE
Technical issues
Normal knee
US findings in rheumatic diseases:
Osteoarthritis
Gout
Pseudogout
Rheumatoid arthritis
Tendinosis

Guidance for joint injection

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. Its 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

Slide collection from Rheumatology Division,

Saiful Anwar Hospital, Malang.

Tophus is formed by uric acid crystals deposition around the joints

surrounded by inflammation area. Sometimes should be distinguished with
other nodules.
 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

DVT on calf

Ruptured Baker cyst

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 guided injection

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

 Accuracy of knee injections

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):18629.
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):205.
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):220913.

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 in rheumatic
diseases.

Terima kasih dan semoga

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