Basic musculoskeletal ultrasound abnormalities: definitions and appearance

Dr. Kai-Len Tsai M.D

Attending Physician, Taipei Medical University Hospital

Learning Objective

• To detect, assess and score synovial, tenosynovial

and entheseal inflammatory activity

• To detect, assess and score structural joint

damage(i.e. bone, tendons, cartilage

outline

1. Joint effusion

2. Synovial hypertrophy,

3. Tenosynovitis,

4. Enthesopathy, enthesitis,

5. Bursitis,

6. Bone abnormalities,

7. Cartilage lesions

1. Joint effusion 關節積液

• Synovial Fluid

• Abnormal hypoechoic or anechoic (relative to

subdermal fat, but sometimes may be isoechoic or

hyperechoic) intraarticular material that is

displaceable and compressible, but does not exhibit

Doppler signals

Anechoic 無回音

Hypoechoic 低回音

Isoechoic 同回音

Hyperechoic 高回音

膝關節 Knee

髖關節 HIP joint

肩關節 shoulder 肩唇

蹠骨關節 MTP joint

腕關節 Wrist joint

肘關節 Elbow 踝關節Ankle joint

Joint effusion

關節積液

A small quantity of fluid can be

present in the normal

joint (arrow). Long-axis view of the 2nd PIP joint flexor aspect.

dorsal osteophytes of PIP joint

Grey scale scoring of joint effusion and synovial hypertrophy

• Semi-quantitative scoring system

• Grade 0: No effusion

• Grade 1: Minimal amount of joint effusion

• Grade 2: Moderate amount of joint effusion[little

distension of the joint capsule]

• Grade 3: Extensive amount of joint effusion[with

high distension of the joint capsule]

J Rheumatol. 2005 Dec;32(12):2485-7.

Grade 1Grade 0

Grade 2Grade 3

Joint effusion grading

2. Synovial hypertrophy滑膜增生

• Abnormal hypoechoic (relative to subdermal fat, but

sometimes may be isoechoic or hyperechoic)

intraarticular tissue that is non-displaceable and

poorly compressible and which may exhibit Doppler

signals

腕關節 Wrist joint

踝關節 Ankle joint

膝關節 Knee joint 蹠骨關節 MTP joint

Synovial hypertrophy &Doppler ultrasonography

• Doppler ultrasonography:

• Is able to visualize blood flow by the change in frequency of sound waves reflected by moving objects(termed the Doppler shift), such as the cells inside blood vessels)

• CDUS technique is affected by the direction of blood flow, whereas the images obtained by PDUS are not direction-coded(able to detect a very slow blood flow rate, which is typical for inflamed joints and tendon areas is patients with RA

Active or inactive

• In the detection of highly vascularized pannus tissue,

which indicates active inflamed joints and tendons,

and furthermore, in the differentiation of active and

inactive RA.

Scoring system

• Inflammatory or active synovial hypertorphy(greyscale scoring)

• Grade 0 :No hypoechoic synovial thickening

• Grade 1 :Minimal hypoechoic synovial thickening(filling the angle between the periarticular bones, without bulging over the line linking tops of the bones)

• Grade 2 : Hypoechoic synovial thickening bulging over the line linking tops of the periarticular bones but without extension along the bone diaphysis

• Grade 4 : Hypoechoic synovial thickening bulging over the line linking tops of the periarticular bones and with extension to at least one of the bone diaphses

GSUS semiquantitatively

3 . Severe synovitis. 2 . moderate,

1 . mild, 0 . absence,

Grade 1 describes a small hypoechoic/anechoic line

beneath the joint capsule.

Grade 3 characterizes a strong

distension of the joint capsule

Grade 2, the joint capsule is

elevated parallel to the joint area.

掌指關節 MCP joint

腕關節 Wrist

掌指關節，腹面

OMERACT-EULAR PDUS composite scoring of synovitis

• Grade 0 (normal) : no synovial hypertrophy, no Doppler signals

• Grade 1 : minimal synovitis, minimal synovial hypertrophy, with (or without) no more than grade 1 Doppler signal

• Grade 2: moderate synovitis• Moderate synovial hypertrophy with or without no more than

grade 2 Doppler signal

• Minimal synovial hypertrophy and grade 2 Doppler signals

• Grade 3: Severe synovitis• Severe synovial hypertrophy with or without Doppler signal

• Minimal/moderate synovial hypertrophy and grade 3 Doppler signal

掌指關節 MCP joint

請問現在您區分出關節積水和滑膜增生的區域嗎?

*

請問您對這關節的power Doppler

signals 評幾分?

Grading?

3. Tendon lesions 肌腱

• Tenosynovitis 肌腱滑膜炎

• hypoechoic or anechoic synovial sheath widening or

thickening(effusion),

• tendon thickness

• peritendinous ± intra-tendinous PD or CD Doppler

signal

• Tendinitis 肌腱炎

• Tendon rupture

Normal biceps tendonTarget sign

Tenosynovitis (RA patient)

Tenosynovitis (Gouty arthritis)

Ankle joint lateral view

Peroneal tendon tenosynovitis

A RA patient

Trigger finger

Tendinitis (Achilles tendon，沒有sheath!

Tenosynovitis

Tendinitis

Achilles tendon

Ankylosing spondylitis

Calcification tendinitis

Tenosynovitis scoring

• Scoring Doppler in tenosynovitis

• Grade 0 : No peri-tendinous signals

• Grade 1 : Focal pen-tendinous signals

• Grade 2 : Multifocal peri-teninous signals

• Grade 3 : Diffuse peri-tendinous signals

4. Enthesopathy, enthesitis著骨點病變，附骨點病變

• Abnormally hypoechoic (loss of normal fibrillar

architectur) and/or thickened tendon or ligament at

its bony attachment (may occasionally contain

hyperechoic foci consistent with calcification), seen

in 2 perpendicular planes that may exhibit Doppler

signals and /or bony changes, including

enthesophytes, erosion, or irregularity)

Achilles tendon

These two pictures are both belonging to one AS patient

with left heel pain. Which is left one?

Knee deep infrapatellar bursa

5. Bursitis 滑囊炎Bursitis is the inflammation of one or more

bursae (small sacs) of synovial fluid in the body.

1. Shoulder bursa

• subacromnal-subdeltoid bursa: At ultrasound it appears as a very thin uniform, 1to 2 mm hypoechoic layer of synovial fluid surrounded by hyperchoic bursal wall and peribursal fat layers.

• Abnormal distention of the SASD bursa may appear anechoic or hypoechoic from simple fluid, or it may range from hypoechoic to hyperechoic as a result of complex fluid or synovial hypertrophy.

Supraspinatus tendon

Subdeltoid bursa

Subdeltoid bursitis

normal

類風濕結節 not bursa !

Gouty arthritis patient

Olecranon bursa

hemorrhagic bursitis of great trochanter

Patellar bone

Patellar bonenormal

Knee bursa

Baker’s cyst

Baker’s cyst rupture

6. Bone abnormalities

• Bone erosion

• An intra-articular discontinuity of the bone surface that

is visible in 2 perpendicular phanes

• Osteophytes

• Cortical protrusion seen in two planes

Semiquantitative scoring system of bone erosion

• metacarpophalangeal (MCP) joints

• normal: <2 mm;

• small erosion: 2 mm;

• moderate erosion: >2–<4 mm;

• large erosion: ≥4 mm.

Scoring erosion• 2nd MCP joint dorsal views

• 0: no ersion

• 1: <1mm

• 2: 1~2mm

• 3: 2~4mm

• 4: >4 mm

Rheumatology 2004;43:829–838

Bone erosion

normal

Osteophyte

7. Cartilage lesions

• Cartilage pathology

• Thining

• Loss of hypo-eccogenisity

• Total disappearance

• Crystal disease

• Double contour sign

• Intracartilage calcification

normal

Not double contour sign

double contour signCrystal disease

Double contour sign

Intracartilage calcification

Rheumatology (Oxford) July 1, 2007 vol. 46 no. 7 1116-1121

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