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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
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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
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OUTLINE
• Technical issues
• Normal knee
• US findings in rheumatic diseases: Osteoarthritis
Gout
Pseudogout
Rheumatoid arthritis
Tendinosis
• Guidance for joint injection
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Klinik Reumatik dan Osteoporosis Paviliun RS Saiful Anwar Malang
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Bimbingan tindakan injeksi intra-artiuler
PPDS IPD FKUB – RSSA Malang
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Equipment
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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.
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Transducer positioning
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Transducer movements
Heel-toe maneuver Toggle maneuver
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Normal knee
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Anterior (sagittal view)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Anterior (transversal view)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Anterior (pre-patellar)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Anterior (flexion)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Medial (coronal view)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Lateral (coronal view)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Posterior (transverse view)
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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US findings in rheumatism
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Knee effusions
Suprapatellar bulging with positive patellar tap test on knee commonly
represent knee joint effusions
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Knee joint effusion
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Knee joint swelling in OA patients
Slide collection from Rheumatology Division,
Saiful Anwar Hospital, Malang.
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Slide collection from Rheumatology Divison, Saiful Anwar Hospital, Malang.
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Intra-articular hemorrhage
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Osteophytes in knee OA
Osteophyte (spur formation) is a bony-enlargement commonly at joint
margin. It’s a typical findings in OA patients
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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.
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Joint cartilage damages
Cartilage damages are early pathologic process in OA
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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.
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Acute monoarthritis
Acute arthritis on knee may caused by gouty attack, possibility of septic
arthritis must be excluded.
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Gout: double contour sign
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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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 : [email protected]
Slide collection from Rheumatology Division, Saiful Anwar Hospital, Malang.
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2015 GOUT Classification
Criteria (ACR/EULAR)
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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.
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Tophus: Hallo sign
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Pseudogout: chondrocalcinosis
Pseudo-gout is caused by calcium pyrophospate dihydrate (CPPD)
deposition within the joints causing inflammation and joint cartilage
calcification (chondrocalcinosis)
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Pseudogout: chondrocalcinosis
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Baker cyst
Posterior swelling at knee joint in OA patients commonly caused by Baker
cyst.
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Baker cyst: comma sign
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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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.
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Ruptured Baker cyst
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Pre-patellar bursitis with effusion
Slide collection from Rheumatology Division, Saiful Anwar Hospital, Malang.
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Prepatellar bursa
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Patellar tendon tendinosis
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Quadriceps tendinosis
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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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.
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Joint erosions on wrist
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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Pannus in RA
Pannus are proliferative synovium with cells
accumulation and high vascularisation within
the joint lead to develop joint erosions.
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Synovial hypertrophy
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound (2nd ed). Elsevier Saunders, 2013.
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US guidance for joint injection
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In-plane and out-of-plane
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Standoff positioning
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US guided injection
Spinner DA et al (Eds). Atlas of ultrasound guided musculoskeletal injection. Springer,2014.
Lateral approach knee injection
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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.
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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.
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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.
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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
bermanfaat