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Ultrasound in hip pain - What else to look for
S46
Ultrasound in Medicine & Biology
GBP of 7-9 mm: Follow-up after 12 and 36 months is recommended. If (during the follow-up period) the GBP size increases 2 mm or if the GBP size reaches 10 mm, surgical treatment (cholecystectomy) is recommended. GBP of 6 mm and less: No treatment or follow-up is recommended.
SESSION 9I: PAEDIATRICS - MSK To Graf or not to Graf: Paediatric hip ultrasound Cain Brockely Chief Sonographer, Royal Children’s Hospital, Melbourne, VIC, Australia Sonography is the imaging of choice for the initial assessment of a patient who presents with suspected developmental dysplasia of the hip (DDH). DDH is a condition that results in abnormal development of the femoral head and acetabulum. When detected early using ultrasound the condition is easily treated via non-invasive bracing of the legs to enable the acetabular cartilage to mold and develop over a period of months until normal. A late detection or missed DDH can result in the need for surgery and therefore the potential for early onset osteoarthritis later in life. Ultrasound has proven to be a great screening resource for DDH however it is known to be extremely operator dependent. It is therefore very important that sonographers ensure they know the techniques, diagnostic criteria and classifications, as well as pitfalls when performing hip sonography. One such pitfall I have seen over the years is the incorrect use of the Graf classification. Graf angles and diagnostic criteria are extremely useful in the diagnosis and follow up of DDH if utilized and applied correctly. This presentation will demonstrate how to focus on technique and landmarks, when and how to apply Graf’s diagnostic measurements, and most importantly how to avoid the common pitfalls.
Ultrasound in hip pain - What else to look for Lino Piotto Tutor Sonographer, Women’s and Children’s Hospital, Adelaide, SA, Australia When investigating hip pain it is important to have a symptomatic approach. Infants are generally not able to be specific about where their pain is originating from and they are unreliable historians. Signs of hip pathology include not weight bearing, walking with a limp and reduced joint movement. The most common cause of hip pain is transient synovitis which may occur following viral infection, allergic reaction or trauma, but is usually of unknown aetiology. Other pathologies to consider are haemarthrosis, septic arthritis, Perthes disease, slipped capital femoral epiphysis and juvenile rheumatoid arthritis. Ultrasound scanning of the hip is best achieved from the anterior approach to assess the synovial capsule. Comparison views are very useful. In the event that the hip joint is normal it is important to remember that there are many other causes of hip symptoms and that any pathological process that involves one of the muscles that control the hip joint may present with signs and /or symptoms suggestive of hip joint disease. Possible pathologies include myositis, bleed, abscess tumour and avulsion. In the absence of primary hip or surrounding muscle pathology the examination should be extended to look for other disease processes which may explain the signs because of their secondary effects on muscles. Such pathologies include appendicitis, pelvic pathology, pyelonephritis, discitis, osteomyelitis, lymphadenopathy or tumour. In the toddler age group two additional diagnoses should be considered, a lower limb fracture and neuroblastoma with secondary involvement of the hip joint. In summary, remember that not all hip pain or hip symptoms relate to the joint itself. All of these can be diagnosed at the time of a hip
Volume 45, Number S1, 2019 ultrasound if a symptomatic approach is used, thereby expediting diagnosis and appropriate treatment.
SESSION 10A: MSK & RHEUMATOLOGY Tendon and muscle imaging in sports injuries Claudia Weidekamm Consultant Radiologist, WDHB Auckland, Auckland, New Zealand Imaging modalities demonstrate a specific pattern for sports injuries that is related to the biomechanical impact. The concept of the musculotendino-osseous chain was developed for sports injuries and is helpful to understand the expected injury pattern of the musculoskeletal system. At up to 55%, the incidence of muscle lesions in acute and chronic sports injuries is relatively high and mainly involve the hip and pelvis. In adolescence injury of the apophysis is common, whereas in younger patients musculotendinous injuries appear. Ultrasound is recommended for assessment of muscle haematoma or seroma, and partial or full thickness tears of the muscles and tendons. In particular the evaluation of the integrity of the musculotendinous unit or muscle hernia is a strength of ultrasound. Magnetic Resonance Imaging is superior in hyperacute muscle injuries and delayed onset muscle soreness. Learning objectives: 1. Impact of ultrasound for imaging musculotendinous injuries. 2. Interpretation and differential diagnosis in acute and chronic trauma. 3. Concept of musculo-tendinous-osseous chain. 4. Typical injury patterns in sports injuries.
DOMS Susan Diep Sonographer, I-MED, Melbourne, VIC, Australia Delayed-onset muscle soreness (DOMS) is familiar experience for athletes and sportsmen and women. It typically presents with swelling, muscle tightness, aching pain, or muscle tenderness. However, this condition is not only limited to the elite athlete demographics, but can also be present in the general population. DOMS is not an acute diagnosis. It typically presents 24 hours after repetitive, strenuous exercise and peaks within 24-72 hours. The time of onset and the time from exercise is crucial in the diagnosis of DOMS, as by day 5 to 7, the patient’s symptoms may resolve. The main cause of DOMS is repetitive eccentric forces which require muscle fibres to lengthen and stretch. Muscle groups that are unaccustomed to this amount of force for a prolonged period of time will suffer trauma. The muscle fibres will undergo microtears on a cellular level that are not detectable with conventional ultrasound, however, the overall appearance of the muscle will appear different in size, echogenicity and texture which can be seen on ultrasound. The extension of the sonographer’s role is to take comprehensive clinical history. This is the key to diagnosis and patient management. Although, there are many differential diagnoses for muscle pain, noting the mechanism of injury plus the time and duration of exercise and will ultimately guide radiologist’s to use DOMS diagnosis appropriately. There are many methods that have been proposed to assess DOMS, including the use of ultrasound, shearwave elastography, MRI and some requiring blood samples. Some may say the ultrasound diagnosis is subjective but it should be encouraged that all sonographers document the changes to the muscular fibrillar patterns. It is important to develop a framework in order to assess for and document the presence of DOMS with ultrasound. The consistency will allow for future assessment in order to discuss changes or improvement to the musculature. With the presence of evolving technology, such as shearwave elastography, sonographers can further quantify the degree of “damage” or “improvement”.
Ultrasound in Medicine & Biology
GBP of 7-9 mm: Follow-up after 12 and 36 months is recommended. If (during the follow-up period) the GBP size increases 2 mm or if the GBP size reaches 10 mm, surgical treatment (cholecystectomy) is recommended. GBP of 6 mm and less: No treatment or follow-up is recommended.
SESSION 9I: PAEDIATRICS - MSK To Graf or not to Graf: Paediatric hip ultrasound Cain Brockely Chief Sonographer, Royal Children’s Hospital, Melbourne, VIC, Australia Sonography is the imaging of choice for the initial assessment of a patient who presents with suspected developmental dysplasia of the hip (DDH). DDH is a condition that results in abnormal development of the femoral head and acetabulum. When detected early using ultrasound the condition is easily treated via non-invasive bracing of the legs to enable the acetabular cartilage to mold and develop over a period of months until normal. A late detection or missed DDH can result in the need for surgery and therefore the potential for early onset osteoarthritis later in life. Ultrasound has proven to be a great screening resource for DDH however it is known to be extremely operator dependent. It is therefore very important that sonographers ensure they know the techniques, diagnostic criteria and classifications, as well as pitfalls when performing hip sonography. One such pitfall I have seen over the years is the incorrect use of the Graf classification. Graf angles and diagnostic criteria are extremely useful in the diagnosis and follow up of DDH if utilized and applied correctly. This presentation will demonstrate how to focus on technique and landmarks, when and how to apply Graf’s diagnostic measurements, and most importantly how to avoid the common pitfalls.
Ultrasound in hip pain - What else to look for Lino Piotto Tutor Sonographer, Women’s and Children’s Hospital, Adelaide, SA, Australia When investigating hip pain it is important to have a symptomatic approach. Infants are generally not able to be specific about where their pain is originating from and they are unreliable historians. Signs of hip pathology include not weight bearing, walking with a limp and reduced joint movement. The most common cause of hip pain is transient synovitis which may occur following viral infection, allergic reaction or trauma, but is usually of unknown aetiology. Other pathologies to consider are haemarthrosis, septic arthritis, Perthes disease, slipped capital femoral epiphysis and juvenile rheumatoid arthritis. Ultrasound scanning of the hip is best achieved from the anterior approach to assess the synovial capsule. Comparison views are very useful. In the event that the hip joint is normal it is important to remember that there are many other causes of hip symptoms and that any pathological process that involves one of the muscles that control the hip joint may present with signs and /or symptoms suggestive of hip joint disease. Possible pathologies include myositis, bleed, abscess tumour and avulsion. In the absence of primary hip or surrounding muscle pathology the examination should be extended to look for other disease processes which may explain the signs because of their secondary effects on muscles. Such pathologies include appendicitis, pelvic pathology, pyelonephritis, discitis, osteomyelitis, lymphadenopathy or tumour. In the toddler age group two additional diagnoses should be considered, a lower limb fracture and neuroblastoma with secondary involvement of the hip joint. In summary, remember that not all hip pain or hip symptoms relate to the joint itself. All of these can be diagnosed at the time of a hip
Volume 45, Number S1, 2019 ultrasound if a symptomatic approach is used, thereby expediting diagnosis and appropriate treatment.
SESSION 10A: MSK & RHEUMATOLOGY Tendon and muscle imaging in sports injuries Claudia Weidekamm Consultant Radiologist, WDHB Auckland, Auckland, New Zealand Imaging modalities demonstrate a specific pattern for sports injuries that is related to the biomechanical impact. The concept of the musculotendino-osseous chain was developed for sports injuries and is helpful to understand the expected injury pattern of the musculoskeletal system. At up to 55%, the incidence of muscle lesions in acute and chronic sports injuries is relatively high and mainly involve the hip and pelvis. In adolescence injury of the apophysis is common, whereas in younger patients musculotendinous injuries appear. Ultrasound is recommended for assessment of muscle haematoma or seroma, and partial or full thickness tears of the muscles and tendons. In particular the evaluation of the integrity of the musculotendinous unit or muscle hernia is a strength of ultrasound. Magnetic Resonance Imaging is superior in hyperacute muscle injuries and delayed onset muscle soreness. Learning objectives: 1. Impact of ultrasound for imaging musculotendinous injuries. 2. Interpretation and differential diagnosis in acute and chronic trauma. 3. Concept of musculo-tendinous-osseous chain. 4. Typical injury patterns in sports injuries.
DOMS Susan Diep Sonographer, I-MED, Melbourne, VIC, Australia Delayed-onset muscle soreness (DOMS) is familiar experience for athletes and sportsmen and women. It typically presents with swelling, muscle tightness, aching pain, or muscle tenderness. However, this condition is not only limited to the elite athlete demographics, but can also be present in the general population. DOMS is not an acute diagnosis. It typically presents 24 hours after repetitive, strenuous exercise and peaks within 24-72 hours. The time of onset and the time from exercise is crucial in the diagnosis of DOMS, as by day 5 to 7, the patient’s symptoms may resolve. The main cause of DOMS is repetitive eccentric forces which require muscle fibres to lengthen and stretch. Muscle groups that are unaccustomed to this amount of force for a prolonged period of time will suffer trauma. The muscle fibres will undergo microtears on a cellular level that are not detectable with conventional ultrasound, however, the overall appearance of the muscle will appear different in size, echogenicity and texture which can be seen on ultrasound. The extension of the sonographer’s role is to take comprehensive clinical history. This is the key to diagnosis and patient management. Although, there are many differential diagnoses for muscle pain, noting the mechanism of injury plus the time and duration of exercise and will ultimately guide radiologist’s to use DOMS diagnosis appropriately. There are many methods that have been proposed to assess DOMS, including the use of ultrasound, shearwave elastography, MRI and some requiring blood samples. Some may say the ultrasound diagnosis is subjective but it should be encouraged that all sonographers document the changes to the muscular fibrillar patterns. It is important to develop a framework in order to assess for and document the presence of DOMS with ultrasound. The consistency will allow for future assessment in order to discuss changes or improvement to the musculature. With the presence of evolving technology, such as shearwave elastography, sonographers can further quantify the degree of “damage” or “improvement”.