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Ultrasound of the small joints of the hands and feet: current status.

McNally EG - Skeletal Radiol. (2007)

Bottom Line: The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques.Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety.Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Nuffield Orthopaedic Centre, Old Road, Oxford OX3 7LD, UK. eugene.mcnally@ndos.ox.ac.uk

ABSTRACT
The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

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Sagittal image of the extensor aspect of an inflamed metacarpo-phalangeal joint (asterisk). Detectable blood flow on power Doppler is seen in more than 50% of the moderately thickened synovium. Note the apparent defect in the metacarpal head (arrow). This is a normal finding and should not be missed or diagnosed as an erosion. Note the well-demarcated floor and lack of through sound transmission
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Fig13: Sagittal image of the extensor aspect of an inflamed metacarpo-phalangeal joint (asterisk). Detectable blood flow on power Doppler is seen in more than 50% of the moderately thickened synovium. Note the apparent defect in the metacarpal head (arrow). This is a normal finding and should not be missed or diagnosed as an erosion. Note the well-demarcated floor and lack of through sound transmission

Mentions: Classifying abnormal Synovial hypertrophy has been measured in a number of ways. Szuldarek categorised changes in synovial thickness by comparing it to bony structures. Grade 1 is minimal synovial thickening (considered normal), grade 2, synovial thickening bulging over the line linking the tops of the bones forming the joint without extension along the bone diaphyses, grade 3, with extension to one of the metadiaphyses and grade 4, extension to both metadiaphyses.The author classifies joint disease using semi-quantitative measurements of synovial thickness, vascularity and association with erosions. Synovial thickness is recorded on a 3-point scale (1–3 = mild, moderate and severe), with moderate synovial thickening between 2 mm and 4 mm above normal. If desired, mild grades of synovitis can be further classified into focal and diffuse, with focal involvement limited to one recess. Moderate and severe synovial thickening is less often focal. This sub-classification may be of value in monitoring more subtle changes, compared with the more two-dimensional classification. A 3-point scale is also used to record blood flow: mild is defined as a few scattered vessels only (Fig. 11), moderate as less than 50% vascularity in the synovium (Fig. 12) and severe as more than 50% (Fig. 13). Finally, 0 and 1 are used to denote the presence or absence of erosions, though where necessary for record or research purposes, a more detailed description of the proportion of bone involvement by erosions can be used. The score is recorded on the ultrasound image, together with annotation of the joint being measured. In summary, the second right MCPJ, with 3 mm of synovial thickening, diffusely involving the joint, with marked increased in blood flow and without erosions, would be classified as R3M 230. Images are printed as hard copy or stored on the department’s picture-archiving communication system (PACS) for future comparison and to monitor the patient’s progress.Fig. 11


Ultrasound of the small joints of the hands and feet: current status.

McNally EG - Skeletal Radiol. (2007)

Sagittal image of the extensor aspect of an inflamed metacarpo-phalangeal joint (asterisk). Detectable blood flow on power Doppler is seen in more than 50% of the moderately thickened synovium. Note the apparent defect in the metacarpal head (arrow). This is a normal finding and should not be missed or diagnosed as an erosion. Note the well-demarcated floor and lack of through sound transmission
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC2141652&req=5

Fig13: Sagittal image of the extensor aspect of an inflamed metacarpo-phalangeal joint (asterisk). Detectable blood flow on power Doppler is seen in more than 50% of the moderately thickened synovium. Note the apparent defect in the metacarpal head (arrow). This is a normal finding and should not be missed or diagnosed as an erosion. Note the well-demarcated floor and lack of through sound transmission
Mentions: Classifying abnormal Synovial hypertrophy has been measured in a number of ways. Szuldarek categorised changes in synovial thickness by comparing it to bony structures. Grade 1 is minimal synovial thickening (considered normal), grade 2, synovial thickening bulging over the line linking the tops of the bones forming the joint without extension along the bone diaphyses, grade 3, with extension to one of the metadiaphyses and grade 4, extension to both metadiaphyses.The author classifies joint disease using semi-quantitative measurements of synovial thickness, vascularity and association with erosions. Synovial thickness is recorded on a 3-point scale (1–3 = mild, moderate and severe), with moderate synovial thickening between 2 mm and 4 mm above normal. If desired, mild grades of synovitis can be further classified into focal and diffuse, with focal involvement limited to one recess. Moderate and severe synovial thickening is less often focal. This sub-classification may be of value in monitoring more subtle changes, compared with the more two-dimensional classification. A 3-point scale is also used to record blood flow: mild is defined as a few scattered vessels only (Fig. 11), moderate as less than 50% vascularity in the synovium (Fig. 12) and severe as more than 50% (Fig. 13). Finally, 0 and 1 are used to denote the presence or absence of erosions, though where necessary for record or research purposes, a more detailed description of the proportion of bone involvement by erosions can be used. The score is recorded on the ultrasound image, together with annotation of the joint being measured. In summary, the second right MCPJ, with 3 mm of synovial thickening, diffusely involving the joint, with marked increased in blood flow and without erosions, would be classified as R3M 230. Images are printed as hard copy or stored on the department’s picture-archiving communication system (PACS) for future comparison and to monitor the patient’s progress.Fig. 11

Bottom Line: The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques.Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety.Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Nuffield Orthopaedic Centre, Old Road, Oxford OX3 7LD, UK. eugene.mcnally@ndos.ox.ac.uk

ABSTRACT
The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

Show MeSH
Related in: MedlinePlus