Essential Applications of Musculoskeletal Ultrasound in Rheumatology: Expert Consult Premium Edition: Enhanced Online Features and Print, 1e

358 Pages·2010·115.669 MB·English

by  Richard J. Wakefield, Maria Antonietta D'Agostino

Essential Applications of
Musculoskeletal Ultrasound
in Rheumatology
Richard J. Wakefield, BM, MD, FRCP (Lond)
Senior Lecturer and Honorary Consultant in Rheumatology
Academic Section of Musculoskeletal Disease
Leeds Institute of Molecular Medicine
Chapel Allerton Hospital
Leeds, United Kingdom
Maria Antonietta D’Agostino, MD, PhD
Associate Professor of Rheumatology
University of Versailles-Saint Quentin en Yvelines
Ambroise Paré Hospital
Boulogne-Billancourt, France
1600 John F. Kennedy Blvd.
Suite 1800
Philadelphia, PA 19103-2899
ESSENTIAL APPLICATIONS OF MUSCULOSKELETAL  
ULTRASOUND IN RHEUMATOLOGY  978-1-4377-0127-2
Copyright © 2010 by Saunders, an imprint of Elsevier Inc.
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Library of Congress Cataloging-in-Publication Data
Wakefield, Richard J.
     Essential applications of musculoskeletal ultrasound in rheumatology / Richard J. Wakefield,
Maria Antonietta D'Agostino. -- 1st ed.
         p. ; cm.
     Includes bibliographical references.
     ISBN 978-1-4377-0127-2
  1.  Rheumatism--Ultrasonic imaging.  2.  Rheumatology.  I. D'Agostino, Maria Antonietta. II. Title. 
           [DNLM: 1.  Rheumatic Diseases--ultrasonography.  2.  Musculoskeletal  System--ultrasonography.  3.  Ultrasonography-- 
methods.  WE 544 W147e 2010]
     RC927.W35 2010
     616.7'2307543--dc22  2010000915
Acquisitions Editor:  Pamela Hetherington
Publishing Services Manager: Tina Rebane
Project Manager: Norm Stellander
Design Direction: Lou Forgione
Printed in China
Last digit is the print number: 9  8  7  6  5  4  3  2  1
To Naz, Sophia and Hannah,
For their patience, support, and encouragement
RJW
To my family,
For their love and untiring encouragement
MADA
Contributors
MARINA BACKHAUS, MD, PhD J. ANTONIO BOUFFARD, MD
Department of Rheumatology and Clinical Immunology  Orthopedic Radiologist
Charité–University Medicine Berlin  Department of Diagnostic Radiology
Berlin, Germany Henry Ford Hospital
Tendons Detroit, Michigan;
Consultant Radiologist
PETER V. BALINT, MD, PhD, FRCP (GLASGOW) Orthopedics and Sports Medicine Sections
Consultant Rheumatologist James Andrews Orthopedics and Sports Medicine Center
Head, Department of Rheumatology  Pensacola, Florida;
National Institute of Rheumatology and Physiotherapy  Sports Medicine Team
Budapest, Hungary United States Olympic Committee
Pitfalls of Gray-Scale Artifacts Colorado Springs, Colorado
The Normal Joint Ultrasound in Sports Medicine
Interventional Musculoskeletal Ultrasound
S. LORI BRIDAL, PhD
SZABOLCS BENIS, MD Parametric Imaging Laboratory 
Department of Anatomy, Histology, and Embryology University of Paris
Semmelweis University Paris, France
Budapest, Hungary Physics of Ultrasound
The Normal Joint
ANDREW K. BROWN, MBCHB, MRCP, PhD
HILDE BERNER-HAMMER, MD Senior Lecturer in Medical Education and Rheumatology
Senior Consultant in Rheumatology Hull and York Medical School
Department of Rheumatology   University of York;
Diakonhjemmet Hospital Consultant Rheumatologist
Oslo, Norway York Hospitals NHS Foundation Trust
Purchasing Ultrasound Equipment York, United Kingdom
Training and Education in Rheumatology Ultrasound:
DAVID BONG, MD Objectives and Challenges
Rheumatologist 
GEORGE BRUYN, MD, PhD
Research Associate 
Poal Institute of Rheumatology  Consultant Rheumatologist 
Barcelona, Spain Ijsselmeer Hospital
Soft Tissue Rheumatism Lelystad, The Netherlands
Shoulder
vii
viii Contributors
PAZ COLLADO RAMOS, MD,PhD LASZLO IRSAY, MD
Pediatric Rheumatology Unit Assistant Lecturer 
Rheumatology Department University of Medicine and Pharmacy  
Hospital Severo Ochoa Department of Physical Medicine and Rehabilitation 
Madrid, Spain Rehabilitation Hospital
Use of Ultrasonography in the Pediatric Patient Cluj-Napoca, Romania
Pitfalls of Gray-Scale Artifacts
MARIA ANTONIETTA D'AGOSTINO, MD, PhD
SANDRINE JOUSSE-JOULIN, MD
Associate Professor of Rheumatology
University of Versailles Saint-Quentin-en-Yvelines  Department of Rheumatology 
Ambroise Paré Hospital Brest University Medical School; 
Boulogne-Billancourt, France Sonographist 
Enthesitis Cavale Blanche Hospital 
Spondyloarthritis Brest, France
Future Advances in Musculoskeletal Ultrasound Salivary Glands
Lower Limb Enthesis in Children
EMILIO FILIPPUCCI, MD, PhD
GURJIT S. KAELEY, MBBS, MRCP
Senior Lecturer in Rheumatology 
Department of Rheumatology  Assistant Professor of Medicine  
Marche Polytechnic University Director of Musculoskeletal Ultrasound 
Ancona, Italy Certified Clinical Densitometrist 
Cartilage Division of Rheumatology 
Crystal-Associated Synovitis University of Florida
Jacksonville, Florida
HENRY GOITZ, MD Training and Education in Rheumatology Ultrasound:
Academic Chair, Sports Medicine Institute American Experience
Director of Education, Research, and Injury Prevention Center
DAVID KANE, MD, PHD
Codirector of Orthopaedic Surgery Sports Medicine  
Fellowship Program Clinical Senior Lecturer and Consultant Rheumatologist  
Vice Chief of Surgery Department of Rheumatology
Detroit Medical Center Adelaide and Meath Hospital  
Detroit, Michigan Trinity College
Ultrasound in Sports Medicine Dublin, Ireland 
Purchasing Ultrasound Equipment
WALTER GRASSI, MD
JOANNE KITCHEN, MD
Professor of Rheumatology 
Chief, Department of Rheumatology Specialist Registrar
Marche Polytechnic University Department of Rheumatology
Ancona, Italy Adelaide and Meath Hospital
Cartilage Dublin, Ireland
Crystal-Associated Synovitis Purchasing Ultrasound Equipment
MARWIN GUTIERREZ, MD ANDREA SABINE KLAUSER, MD
Department of Rheumatology  Associate Professor of Radiology 
Marche Polytechnic University Department of Radiology 
Ancona, Italy Medical University Innsbruck 
Crystal-Associated Synovitis Innsbruck, Austria
Contrast-Enhanced Ultrasound
ANNAMARIA IAGNOCCO, MD
Assistant Professor of Rheumatology 
Sapienza University of Rome
Rome, Italy
Osteoarthritis
Contributors ix
KOK OOI KONG, MD ESPERANZA NAREDO, MD
Senior Consultant Rheumatologist  Rheumatology Department 
Rheumatology Service  Hospital Severo Ochoa;  
Department of Rheumatology, Allergy and Immunology  Ultrasound School
Tan Tock Seng Hospital  Spanish Society of Rheumatology
Singapore, Malaysia Madrid, Spain
Training and Education in Rheumatology Ultrasound: Training and Education in Rheumatology Ultrasound:
Asian Experience European Experience
MICHELE LAMURAGLIA, MD PHILIP O'CONNOR, MBBS, MRCP, FRCR
Chief Resident Consultant Skeletal Radiologist 
Parametric Imaging Laboratory;  Department of Radiology 
Service of Medical Oncology  Leeds General Infirmary 
Georges Pompidou European Hospital;  Leeds, United Kingdom
National Cancer Institute Future Advances in Musculoskeletal Ultrasound
Bari, Italy
Physics of Ultrasound LAJOS PATONAY, MD, DDA
Department of Anatomy, Histology and Embryology
PETER MANDL, MD, PhD
Semmelweis University
Consultant Rheumatologist  Budapest, Hungary
Department of Rheumatology The Normal Joint
National Institute of Rheumatology and Physiotherapy 
Budapest, Hungary CARLOS PINEDA, MD
Pitfalls of Gray-Scale Artifacts Professor of  Rheumatology 
The Normal Joint La Salle University School of Medicine; 
Interventional Musculoskeletal Ultrasound Biomedical  Research 
National Institute for Rehabilitation 
JOHAN MICHAUD, MD
Mexico City, Mexico
Assistant Professor of Physiatry  Training and Education in Rheumatology Ultrasound:
Consultant in Musculoskeletal Ultrasound  Latin American and Caribbean Experience
Department of Internal Medicine 
Hospital Notre Dame, Chum  PHILIP ROBINSON, MBCHB, MRCP, FRCR
University of Montreal  Consultant Musculoskeletal Radiologist 
Montreal, Quebec, Canada Leeds Teaching Hospitals; 
Peripheral Nerves Musculoskeletal Centre X-Ray Department 
Chapel Allerton Hospital 
EUGENIO DE MIGUEL MENDIETA, MD, PhD
Leeds, United Kingdom
Consultant Rheumatologist Muscle
Hospital University La Paz;  
Professor WOLFGANG A. SCHMIDT, MD, PhD
Ultrasound School Rheumatologist 
Spanish Society of Rheumatology  Medical Center for Rheumatology Berlin-Buch,
Autonomous University of Madrid Berlin, Germany
Madrid, Spain Vasculitis
Soft Tissue Rheumatism
MARCIN SZKUDLAREK, MD, PhD
INGRID MÖLLER, MD
Rheumatologist 
Staff Rheumatologist  Department of Rheumatology
University Hospital Plato University of Copenhagen
Barcelona, Spain Hvidovre and Glostrup Hospitals 
Soft Tissue Rheumatism Copenhagen, Denmark
Rheumatoid Arthritis
x Contributors
LENE TERSLEV, MD, PhD RICHARD J. WAKEFIELD, BM, MD, FRCP
Consultant  Senior Lecturer, Honorary Consultant in Rheumatology
Department of Rheumatology  Academic Section of Musculoskeletal Disease
Copenhagen University Hospital Hvidovre  Leeds Institute of Molecular Medicine 
Copenhagen, Denmark Chapel Allerton Hospital
Pitfalls in Doppler Ultrasound Leeds, United Kingdom
Synovitis Detection of Bone Erosions
Muscle
Future Advances in Musculoskeletal Ultrasound
Foreword
Ultrasonography has taken the rheumatology world by storm  respected European League Against Rheumatism (EULAR) 
as  its  new  stethoscope,  with  proven  benefits  in  diagnosis,   Ultrasound courses. Their experience is reflected in practical 
management, and guided therapeutic intervention for many  chapters that provide details on normal anatomy as well as the 
common  musculoskeletal  conditions.  However,  the  rapid  spectrum of relevant joint soft tissue and bony pathology.
acceptance of this new imaging modality has resulted in a con- I highly recommend this detailed and informative text 
siderable (as yet often unmet) need for comprehensive training  to all clinicians with an interest in musculoskeletal ultrasono-
 programs. With that in mind, Drs. Wakefield and D’Agostino,  graphy, both trainees and experienced sonographers. 
both  leaders  in  the  rheumatology  ultrasound  world,  have 
compiled an impressive and well-illustrated text covering all  Philip G. Conaghan, MBBS, PhD, FRACP, FRCP
the major aspects of musculoskeletal ultrasonography, includ- Professor of Musculoskeletal Medicine
ing adult and pediatric areas. The breadth and depth of this  University of Leeds, United Kingdom
textbook are a tribute to the editors and authors, who have for  Chair, EULAR Standing Committee on
many years dedicated themselves to being teachers of the highly  Musculoskeletal Imaging
xi
Preface
This book evolved because of a need for an up-to-date practi-  fundamental pathologic lesions and finishing with an evidence-
cal text that accurately reflects the needs of the clinical rheu- based review of how ultrasound can be best applied in clinical 
matologist and related professional. As a result, it is largely  practice. The authors have tried to make the chapters as  practical 
 disease focused, with a particular emphasis on the inflamma- and clinically relevant as possible.
tory arthropathies. It was originally conceived as an accompani- We hope that you find this book easy and enjoyable to 
ment to the successful European League Against Rheumatism  read as well as relevant and informative. To encourage learn-
(EULAR) Sonography courses, which are now entering their  ing, the authors have provided accompanying self- assessment 
thirteenth year. These courses are run by experienced and enthu-  questions and video clips on the Expert Consult website. 
siastic clinicians and academics with an interest in ultrasound  Finally, we would like to acknowledge with special thanks, 
who are at the forefront of ultrasound research and develop- our friends and colleagues who are the authors of this book and 
ment. This book therefore reflects the collective experience of  without whom this book would not be possible. Additionally, 
many years of research and teaching by these tutors. we would like to thank the editorial team at Elsevier, with spe-
We have intentionally not produced an atlas or manual  cial mention to Pamela Hetherington, for her patience, guid-
for acquiring and interpreting images. Rather we have tried to  ance, and commitment to the whole project.
follow a format similar to the EULAR courses, starting with  Richard J. Wakefield
basic  principles  including  physics  and  descriptions  of  the 
Maria Antonietta D’Agostino
xiii
1
S. Lori Bridal and Michele Lamuraglia
Physics of Ultrasound
KEY POINTS Imaging provides real-time visualization. Ultrasonic 
probes can be constructed from a tightly spaced row of small 
• Ultrasonic waves are elastic, mechanical waves.
piezoelectric elements that generate and detect ultrasound 
• Ultrasound imaging is safe and noninvasive.
energy (i.e., transducer array). Transmission and reception 
• Imaging provides real-time visualization.
channels are switched on and off sequentially from one 
• Contrast imaging improves vascular detection. group of elements to another to interrogate along different 
sound paths. Echo-based imaging speed is limited by the 
pulse's travel time to and back from the deepest part of the 
Characteristics of Ultrasound Imaging imaged zone (on the order of 0.1 ms for an 8-cm depth). 
Movements within structures can be observed as they occur. 
Ultrasonic waves are elastic, mechanical waves.1-3 Ultrasound  The velocity and direction of blood flow or other tissue dis-
requires an elastic or viscoelastic medium for propagation.  placements can be evaluated.
In an element of an elastic medium, longitudinal stress (i.e.,  Specific imaging modes are applied for contrast agent 
force per unit area) applied to the medium is proportional  detection. Ultrasound contrast imaging for better delinea-
to the strain (i.e., change in the length divided by the initial  tion of vascularized zones relies on the intravenous injection 
length). This relationship is described by Hooke's law. In a  of stabilized, micrometric gas bubbles. Because microbub-
viscoelastic medium, stress is related to strain amplitude and  bles can oscillate in a unique, nonlinear way in response 
to the rate of strain variation. to an ultrasonic pulse, they can be detected while virtually 
There is mechanical interaction between the wave and  ignoring the background signal from surrounding tissues. 
the body. The wave progressively decreases in amplitude, or  Contrast-specific detection allows visualization of microvas-
is attenuated, as it propagates through the medium because  cular perfusion that cannot be observed by other ultrasonic 
of energy lost through scattering from the principal propaga- techniques.
tion path and lost as heat. Attenuation of the wave increases  Numerous applications take advantage of the nonin-
with increasing frequency. The higher the ultrasound fre- vasive and real-time nature of ultrasound. It is used by many 
quency, the more limited is the accessible imaging depth. specialists, such as obstetricians, cardiologists, radiologist, 
Ultrasound imaging is safe and noninvasive. As the ultra- gastroenterologists, endocrinologists, and surgeons. Rheu-
sonic pulse passes through a medium, molecules within the  matologists apply ultrasound predominately for musculo-
body are reversibly perturbed from their equilibrium positions.  skeletal evaluation.
Images are formed by sensitively detecting echoes of the pulse 
returned from interfaces or from scattering structures within the 
tissue. The relative intensity of a returned echo is represented in 
Ultrasound Mechanisms and Settings
terms of relative pixel brightness. The sound path's orientation 
and the echo time-of-flight are used to map each echo intensity 
to a position in a reconstructed image of the medium. Pulses and Echoes
Systems are relatively low cost. Ultrasonic transducers 
used to initiate and to detect ultrasonic pulses, and the electron- Imagine  a  very  crowded  train  platform  during  a  major 
ics that accompany them are relatively low cost compared with  transportation strike. At the edge of the crowd, somebody 
the equipment necessary for most other imaging techniques.  shoves. Each person is rooted to the spot he or she occu-
This is not a direct result of physics, but physics has helped  pies by the force of the surrounding crowd. Nevertheless, the 
indirectly by providing an elegant solution for the production  shove  travels through the crowd. When it gets to me, I move 
of ultrasonic waves (i.e., piezoelectric c rystals) within the fre- a little bit forward (shoving my neighbor), pull myself back 
quency and amplitude ranges required for medical imaging. the other way, and eventually return to my original position. 
3