Transcript
- Thanks everybody for joining us.
Welcome to the webinar Diagnostic Hand Ultrasound Part
three Arthritic Hand.
My name is Chris Pennell and I'll be
moderating today's webinar.
This is the third webinar in a four part series on the hand
and you can check out the first parts
and sign up for the next part on this webinar series on sono
site.com/behind the scan webinar.
And you can go ahead and scan
that QR code on the screen right now to go directly
to there and sign up.
All of our previous webinars are also available there,
so feel free to take a look at the archives there
for some more educational material.
We have a lot of musculoskeletal content on there,
so I think that you'll really enjoy the other
webinars that we have.
Before we begin, please be advised all attendees are muted.
We'll be conducting a q
and a session at the end of the presentation
and so feel free to send those questions in while the
presentation is going
and then we'll get to those questions at the end of the,
at the end of the presentation at the q and a session.
If you're on the zoom stream,
you can type your questions into the q
and a box, into the toolbar located at the bottom
or the side of your screen.
And for our viewers on the YouTube
and LinkedIn streams, you can enter your questions in the
chat box and those will get forwarded to us
so that we can ask them.
This webinar will be recorded
and archived, future reference on our webinars page
and on the Sono Site Institute
as we have two presenters today.
So first off, I'll introduce Daniel Shelton.
Daniel is the director of musculoskeletal market development
for Fujifilm SonoSite.
Daniel has spent 21 years
as a dedicated musculoskeletal sonographer
and 16 of those years have been here at SonoSite.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point-of-care ultrasound.
And we also have Dr. Daniel Malone here.
Dr. Malone teaches diagnostic
and interventional musculoskeletal ultrasound all over the
nation and he earned his MD from the University of Illinois,
Abraham Lincoln School of Medicine in Chicago.
He was on the faculty of the University of Wisconsin Madison
for 23 years and then chose to join the private sector.
He's a current president
of the Wisconsin Rheumatology Association
and sees patients at the Prairie Ridge Health in Columbus,
Wisconsin and volunteers seeing rheumatology patients at the
Specialty care free clinic in Madison, Wisconsin.
And with that, I'll hand it over to Daniel
to get our presentation started.
- And so we're going to talk about SLI ultrasound
of the arthritic hand.
And as you see here, you're using a linear probe
with the patient's hand on a table at a comfortable level so
that you're both not strained
and experiencing neck and back pain.
And the next image here is a overview
and what we're talking about today is part three
looking at arthritis in the hand.
And as you see, there are these different subheadings
that we're going to talk about.
We'll try and give you a look
as we go through these slides quickly of how to do this
and what to look for.
So when we think about these factors and
before you scan, you have to think about the,
what is the pattern of involvement.
So these are clinical parameters here that you obtained
by your physical examination and history.
And you look at the pattern of involvement.
So you want to know which joints of the hand are involved,
are both hands involved symmetrically or not?
How many joints are affected?
Are there a lot of joints or are just a few?
You take a history for such things as low back pain
and psoriasis to see whether
or not this may be part of a seronegative disorder.
You look at the joints and feel them
and focus on scanning the ones that are symptomatic.
And if you do see what you think is an erosion,
that must always be confirmed in an orthogonal plane
because there's a lot of things
that can fool you into thinking there's an erosion
when in fact there isn't.
So you must always confirm in the orthogonal
or perpendicular plane.
Now these structures shown in this diagram here,
obviously there's the two bones.
The blue stripe is cartilage, this is a dorsal side.
On the top there is the skin
and the subq fat.
The joint capsule here is shown by my arrow.
And you'll notice that on these digital joints,
proximal is to the left here.
So this is a metacarpal bone.
This is a proximal phalanx in all the joints
of the hands and feet.
Synovial joint effusions are going to collect here,
which is proximal
and dorsal to this little notch in the
metacarpal bone in this case.
But all of the bones in the hand are,
are similarly aligned in the structure
of all these joints is pretty similar.
So if there's going to be fluid in the joint,
you're going to see it dorsally and it's going
to be obviously superficial to the cartilage here,
which is in blue.
This little yellow triangle is a fatty connective tissue.
We call it either a joint fat pad or a joint homolog.
The light green blue here is the synovium,
and right
above the synovium is the joint capsule right outside
of if you will, the synovium is the joint capsule,
which obviously holds the synovium in place.
So here are some other structures that are important
in the anatomy of, especially in the hand.
You have these extensions of the lumbrical muscles
and the interosseous muscles you have at least.
Now this is the volar side that's that's facing up.
You have these A one pulley, a two pulley,
a three et cetera, that
hold the tendon down against the bone.
Those are, especially with the new high frequency pros,
those are visible
and they are not necessarily anti coic
with the newer transducers.
So all of these structures are things
to consider when you're talking about arthritis
and before you're going to scan, remember that we,
as we just discussed, if you're looking
for effusions synovitis, dorsal is the place to look you.
It is very good to all confirm your findings,
whether they're erosions
or areas of hyperemia on doppler.
It's always good to confirm those in a transverse or
or orthogonal plane.
There are sometimes when people are larger,
the BMI is is higher.
Sometimes you don't know whether this is just body habitus.
You can make measurements with these machines, for example,
between the bony cortex
and this deep surface of the extensor tendon.
That's one measurement that we often make to see whether
or not the synovium or the joint structures are thickened.
And there are some standards for those.
Doppler is always a good idea when you're talking about
arthritis 'cause you want to know what's inflamed.
And inflammation is really the hallmark
of inflammation is hyperemia.
And those structures that are hyperemic are the ones
that are causing the problem or
or the ones in which the autoimmune attack is taking place.
Vola views are helpful,
but you're, if you're looking for synovitis,
they're not so helpful.
But if you're looking for erosions of the,
the condition of the cartilage,
whether the vola plate is in a, in some way damaged,
and if you want to talk about flexor tendonitis,
then obviously the vola views are going to help you.
So when you talk about these clinical characteristics, we,
we mentioned this a a bit earlier about the symmetry,
which joints are involved.
So for psoriatic arthritis
and many of the other so-called seronegative
inflammatory types of arthritis,
seronegative means rheumatoid factor is negative.
So other than rheumatoid arthritis,
a lot of times you're going to see possy articular,
which means fewer joints involved.
It's commonly asymmetric.
So just because the right third DIP is involved,
that doesn't necessarily mean the left is,
so it's asymmetric.
The dips are commonly affected in these seronegative
types of inflammatory.
Rheumatoid arthritis almost never affects the DIP joints.
Now these other joints can be erosive just like rheumatoid,
but they can also cause these proliferative deformities,
which rheumatoid arthritis never does.
So the sero negatives
and the rheumatoid can vary in the ultrasound appearance
and that helps you with getting an etiology.
So this, on the contrary, here's what's rheumatoid,
it's polyarticular, it is symmetric.
So the left and the right side joints are going to be
equally involved.
It can be erosive but not proliferative.
And in the hands
and feet, which is
what rheumatoid arthritis generally affects.
More often it's going to be MCP joints and the hands
and the MTP joints and the feet, the PIP joints
and then the hands, the the carpal bones.
So the rheumatoid is different than the sero negatives.
And then we can sort of summarize this
using the, here's gout,
which is a different type of inflammatory.
So it has certain characteristics that are listed here, some
of which are depicted in that panels
to the right, which is the double contour sign
and the sort of iso echoic debris that you see in joints.
And you always put the doppler on that
because those iso coic debris are commonly tophus
a collection of monosodium urate which really
angers the synovium.
So the doppler is very helpful there.
Osteoarthritis is proliferative, generally non erosive,
although there are some subcategories
that I don't want to spend too much time on of erosive OA
and inflammatory oa.
But the typical run
of the mill osteoarthritis is cartilage thinning,
bony proliferation.
And it does have a predilection
for especially the DIP joints.
The thumb CMC in the hand, the first toe
MTP joint.
And you'll see a lot of bony spurring
and extra bone formation.
No erosions, you won't see much doppler here
unless you're talking about one of these subcategories.
So here's bony anatomy
and note that in the wrist,
these first carpal row joints are all connected
as are the mid carpal row.
Joints are connected to each other,
but the mid doesn't attach to the proximal
and then the distal rows are also connected.
But again, not to the other two rows.
This is just typical I of the, you don't have
to spend too much time on this.
This is a dorsal view.
These are the anatomical features,
the metacarpal notch here.
This is a normal feature of the bone,
it's the connection point of the joint capsule
and the synovium,
which then is redundant dorsal approximately
for these digit joints.
This is a drawing that Daniel made of the dorsal
anatomy here with the extensor hood,
which is a very complicated structure
and is made up of fascial planes that generally intersect
and blend with each other.
Here's a diagram with an MCP joint showing some
of this anatomy we just talked about in the midsagittal
where you are going to show that extensor tendon so that
that distance then between the bony cortex
and the deep surface of the extensor tendon is one
of the things we generally measure.
And there are some standards for that.
Again, here's another view of a dorsal MCP joint
with the joint homolog.
This is somewhat thickened synovium
and this is osteoarthritis
because there is an extra, a bony spur there.
And this is a typical look at an osteoarthritic joint.
Now the synovium can be a little bit thickened,
but generally you're going to see a a doppler negative joint.
This is the PIP joint, same sort of structure.
The extensor slip here is covering
this joint and now the
extensor hood complex comes into play,
but the extensions of the interosseous
and lumbricals are more split apart.
Here they form part of the dorsal hood complex.
And here's a, a look from
above down onto the dorsal surface
of the PIP joint with these various
tendon slips going from the interosseous
and the lumbricals forming the the dorsal hood complex.
This is a, a slice through it
ultrasound, look at it.
And this is the DIP joint.
Now, so you're, oh, I'm sorry,
this is the PIP joint I I'm mistake.
So this is the PIP joint.
This is the proximal phalanx.
Here's the middle phalanx
and here's the ultrasound appearance of that
with no pressure applied so that you get some of the
soft tissue relationships without any pressure
pushing down on them.
Now here is a case of proximal inal,
anal joint osteoarthritis,
very proliferative, big bony spur.
There you see a little bit of fluid
and other debris within the joint.
And this is a pretty typical look at the
PIP joint, which is affected by osteoarthritis.
And this is a drawing
of a side view and a top toward bottom
or dorsal towards palmar.
Look at the PIP joint
and there's the drawing again on here.
You see the fibro cartilage
covering the middle phalanx.
This is the proximal,
this is the distal phalanx.
And there are these other structures
that are labeled here on the left,
the thumb joint here, the first CMC,
so the carpo metacarpal joint, that is
to say the first metacarpal, the thumb metacarpal
with the trapezium.
This is a very commonly affected joint
for rheumatoid arthritis.
It's good to know the anatomy
and the structure surrounding this
because this is a commonly injected joint.
And the, the structure you have to worry about here,
of course is the radial artery which dives
through the snuff box about right here.
So if you take the palmar approach to this,
the radial arteries already out
of your way if you do it on the palmar side.
But this, this is a good joint to be familiar with
because it's commonly affected by osteoarthritis.
There's another look at it
and I think that kind of does it
for the verbal part of this.
And we can switch to a live demo
today we're going to talk about the use
of ultrasound in the various types of arthritis of the hand.
We're going to exclude the wrist
because that's a, a separate teaching
endeavor entirely.
So we're going to talk about arthritis of the hand.
And when we talk about the hand,
we're talking about basically three sets of joints.
We have the metacarpophalangeal joints,
we have the proximal interphalangeal joints,
and we have the distal interphalangeal joints.
And we first of all take a history
and do a physical examination
because ultrasound essentially is an extension of
what we learn in the history and the physical examination.
So these three sets of joints that we just talked about,
arthritis of the hand can affect any of these joints.
And the pattern that
is demonstrated in which joints are affected tells a lot
about what type of arthritis we're talking about
of the types of arthritis that we deem inflammatory.
The most common are rheumatoid arthritis
and psoriatic arthritis
and the various types
of inflammatory arthritis such as gout.
There are certain other types of course,
but when we're looking for inflammatory synovitis,
the pattern of involvement becomes extremely important.
Important. So some entities like psoriatic arthritis have a
predisposition for these distal interphalangeal joints.
Others like rheumatoid arthritis have a propensity
to involve the metacarpal falange joints
and almost never involve the distal gout
can affect anything.
Osteoarthritis usually affects the proximal
and or the distals less often
the metacarpal flange joints.
So the history and the physical plays a huge role here in
what we're actually going to be looking for.
So when we talk about arthritis of the hand, the history
and the physical is the basis for what we then do.
So if we're going to look,
let's say at a metacarpophalangeal joint for
arthritis and we are looking at an
inflammatory arthritis, I'll always start dorsally
because you actually get a better look
at the joint from the dorsal aspect,
especially when it comes to kind of joint effusions
and synovial thickening as well
as spur formation.
And even erosions, you're going to see the,
these things better dorsally.
So there's, it depend the scanning plane and angle matter.
So if I want to look, if I'm looking at a tendon problem
for example, obviously I'm going to want to place my transducer
over the, over the tendon.
And so I'm going to move laterally and,
and immediately until I get a good look at
that tendon, which has the fibrillar architecture on,
that's the, the longitudinal view.
And remember that the, the tendon doesn't always go over
the part of the joint you're interested in.
So if I'm not so much interested in the tendon
and I'm much more interested in looking at say, synovitis
or bony erosions, erosions
or phony spurs, I'm going to come off the tendon
and maybe even tilt transducer a little bit
to get a better look at the joint.
And so this is be, would be a good example
of looking at the MCP joint dorsally.
And you'll notice that my transducer is not
perpendicular to the floor.
It is actually slanted a little bit,
but I, I get a better look at the joint space this way.
And obviously the joint space is that V in
between the two bones, which is bright white.
And if I lessen my pressure a little bit, you can see
that there is a compressibility to a normal hand.
So there's obviously fluid makes, you know, most
of our tissue is is water.
So if I lessen up my pressure
and then press down, you can see how much of
that subcutaneous tissue is compressible.
So we have to be careful,
especially when we're using doppler
and that's the only time that I will advocate the use
of a lot of gel is when you're trying to look at
doppler signal in tissues
and you don't want to apply
any pressure to the tissue you're scanning.
Only then do I advocate using a big glob of gel.
Otherwise big globs of gel make your transducer slippery
and a make a big mess.
So I start with
just a general scanning technique here
where I'm not needing to use a huge amount of gel.
So I'm looking at the cartilage on the metacarpal head.
In this particular orientation.
Proximal is going to be
to the right side of the screen.
So proximal is to the right.
So I'm looking for spurs which are bony projections.
I'm looking for synovial thickening, which is going to make
the proximal
and distal portions of this joint
thicker in, in digits.
Dorsally fluid is always going to collect
at this area proximal to the metacarpal head
if you're talking about an MCP joint, A PIP joint
or a DIP joint.
So this joint, the fluid is going to collect just proximal
that is to the right on this image of the metacarpal head in
that little hollowed out area
proximal to the cartilage on the metacarpal head.
If we go to the pro, the middle
or proximal interphalangeal joint,
again, even though this is a much smaller joint,
that fluid again is going to collect to the right
of the joint space that is proximal
to the joint space in
that area just proximal to the
PIP joint, just proximal to the
proximal phalanx head,
which is now in the middle of the image.
So that's where that fluid is going to be found.
In the DIP it's the same story.
So now here I am going to need a little more gel
because the DIP is a small joint,
so I'm going to put my, my transducer right over the DIP joint
and you can see that the,
the nail plate is, is, is causing me
to lose contact with the skin
distally, which is to the left.
But there's the joint space now in the middle
and if there's fluid in this joint,
it's going to collect just proximal to the right of
that semilunar brightness on the
middle phalanx.
So again, in the center of the image is
where you're going to see that fluid collect.
And if we take this all the way out,
you can see,
you can see the nail plate.
And the nail plate is that bright line at the,
the superficial most part
and the nail plate meets the cuticle at, in that,
in the middle of the image.
So if you put doppler on this,
the chances are you're going to see some signal
and that is absolutely normal.
The cuticle is very well vascularized
and usually the nail
bed if I can, I don't know if
that's going to allow me to,
yeah, see the nail bed is also highly, this is normal.
This is not infl inflammation, that's normal vasculature
of this area of the finger.
Alright, so if we go back to the proximal joint,
this is a, this is the way I scan it with
just looking for anatomy and synovitis.
And then if I put the doppler on,
I need to lighten up my, my technique,
I'm going to make this doppler box narrower.
Why am I doing that?
Because you get better resolution
of your B mode when you use a a narrow or doppler box.
And I'm going to hit select now to, to, so you, you,
you're going to get better resolution in your B mode
because you're asking the machine to do less doppler,
which takes time
and you allow it to do more bmo.
So I'm looking back here,
I'm looking pretty much up until the joint capsule
attaches.
Now remember there's normal vasculature in the skin.
There's a pretty, there's a pretty robust vascular
supply of normal vessels in the finger.
Now when you see a an A vessel that size,
that's almost surely a normal vessel hyperemia
of synovium first of all is deeper and it's much more lacy
and smaller vessels
with slower velocity.
And we're looking at a pretty slow velocity here.
That's in the, on the scale on the left side of the screen.
So that I would call probably a normal vessel's so big
and I, I'd be hesitant to call
that synovitis.
If I want to get synovitis, I'm going to need to see it
in here and I'm going to need to see it
in these tissues
as I scan back and forth.
It should light up. And the only thing
that lights up here is when I cross over one of those
normal big vessels like that, we'll never see synovitis
with a vessel that big.
All right, so when we look at the anatomy of the
metacarpal head, this is part of it.
And now I'm going to move this transducer from a,
an angle like you see here.
I'm going to come up and just try
and scan the entire digit by going all the way around.
And what I want you to notice is the features
of the metacarpal head.
Okay? So there's the metacarpal head,
I'm going to bring this over
slowly and you'll see that there's
what look could be mistaken for an erosion
of the metacarpal head.
It's that little notch right proximal to the head
between the head and the diaphysis
or the shaft of the bone that is normal,
that is the junction of the metacarpal head
with the diaphysis of the metacarpal bone.
That is a normal appearance that is not an erosion.
And so as, as we come a little bit now, we're pretty much
directly over it
and you can see that that is accentuated when I've got my
probe pretty much perpendicular to the floor.
And then as I slip a little bit off the, the middle of it,
that notch is going to become less prominent
as we go over here.
And that
slope is also normal.
There's no notch anymore.
But that's the slope connecting the metatarsal
or metacarpal head with the metacarpal diaphysis or shaft.
And it is, we remember we've moved our transducer
to a different plane
and as I come around
and really start to get on a, on a
different angle that gets less prominent.
So just remember what the normal anatomy is.
There is this notch between the,
the diaphysis or the, the long part of the bone
and the metacarpal head and, and there we see it again.
So that is normal. When we go to the DI
PIP joint, it's a similar anatomy
but much, much less of a shape
issue with that proximal portion of the joint.
So you don't really see much of a
step off there between the more proximal part
of the middle phalanx
and that distal distal
part near the joint.
So there's a little bit
and you can see that little tiny abdo not abnormality,
normal piece of bone there proximally, which is to the right
of the joint space.
It's not as pronounced as it was with the metacarpal head.
So we're now scanning that proximal interfa N gal joint.
So the proximal phalanx is the bone on the right,
the PIP joint is in the middle
and you can see that that distal portion
of the proximal phalanx, there's that tiny little notch
and nothing like it was on the metacarpal head.
Okay, when we look at this distal joint,
it's even less pronounced.
And there's a couple of tricks you can use
to get a better look at the cartilage when you're,
when you're interested in looking at the surface
of the metacarpal bone, for example,
in this particular image
there is a an koic stripe
of cartilage on the metacarpal head.
And you can see, I'm going to freeze this,
there's the joint, you can see what is dipping down
into the joint.
When we talk about the cartilage,
you'll see that here's the metacarpal head,
there is an koic stripe covering
that metacarpal head.
And then this iso coic thing
that dips down into the joint is called the joint homolog.
All joints, all synovial joints have this
structure dipping down.
It's a normal structure, it's mostly fat tissue
and it gets pushed upward
or superficial when there's fluid in the joint,
which makes it even easier to see.
But when we're talking about this cartilage here,
if you're interested in such things as
deposits of monosodium urate crystals, which will also,
which will often be a frosting basically on the surface
of this cartilage
or in calcium pyrophosphate dihydrate disease,
will actually have
echogenic objects embedded within this cartilage.
It helps to get a better look at the cartilage.
And the trick for that is to put the patient's hand
on a, an object such as this so that you can
have the patient flex this joint
and now you can get an even better look
at more of that cartilage.
This is a good trick to use in assessing a patient
for the double contour sign of gout,
which will be more apparent the, with the, the joint flexed.
And if you can flex it even more just like this,
this makes it a little harder to scan,
but you can get a really good look at that cartilage
and follow it kind of all the way
around the corner like I'm doing here to see it.
And then you can look at objects within that cartilage.
If there are, if they are there
and it gives you some idea whether this is monosodium urate
crystal or CPPD, it's not perfect.
The two may resemble each other
and some unfortunate individuals may have both.
But this is a good trick to be able to see more of
that cartilage is to do this inflection.
Okay, another trick we use to for calibration,
most patients have very robust
flow to the fingertip pads on the vola aspect.
Now if you're talking about somebody
with Raynaud's phenomena,
then you're not going to be able to depend on this.
But the normal person, let's have her now
turn her hand over.
And this is a good way to,
to calibrate whether you've got the proper settings
for your doppler.
And what you do is you put a pretty decent sized blob on
there because you don't want to exert any pressure
to tamponade the, the flow to the fingertip.
But the fingertip has a very robust flow of,
of blood
and you, when you turn on the doppler,
the probably the single most important parameter on your
screen is going to
be this parameter, right?
Where is that here, where that,
oh yeah, this parameter, we won't go down there.
Oh wow. Alright.
The 661 hertz,
that is basically the same parameter
as the speed of the blood
that you can detect,
which is here in centimeters per second.
Here it's expressed in a different parameter,
but it means basically the same thing.
The lower this frequency down here,
pulse repetition frequency of,
in this case 661.
If I lower that, which I can do
at will, the lower that number, you'll see
that the lower the flow we can detect the lower the speed
of the flow, we can, we can detect.
Now that's important in synovitis
because the flow of the blood in synovial tissue
that's inflamed is quite slow
because the vessels are very small.
So you may need to lower that
PRF pulse repetition frequency, also known as the speed
of the flow.
You can detect if you're looking for very, very small
and slow moving blood.
Well how do you know whether you're going
to be able to detect that?
Well you check it in the fingertip.
And so with this setting, this is looking for very low flow.
If I now take my transducer
and apply it very, very gently
notice that I am seeing a lot
of flow in that finger pad, that is normal.
Now if I push too hard, I,
I can pretty much make it go away.
If I set my pulse repetition frequency up too high,
I will not be able to detect this low velocity flow.
This is what it should look like in a normal fingertip.
If it's 60 degrees in your exam room
and the patient is freezing
and her blood vessels are all constricted,
that's obviously going to affect this.
So the patient has to be comfortable, not cold,
they cannot have renou phenomenon.
And this is
what you should see when you apply virtually no
pressure and scan a fingertip
and you may have to move the transducer back
and forth in order to, to see all the,
the blood flow in the fingertips.
So that's what I'm doing here.
And notice that if I move my transducer like that,
I create artifactual flow.
So you got to, you got to have a,
a very steady hand to do this.
The other thing I even noticed is sometimes
the low frequency
of my voice can affect this.
Now in this case it's not happening,
but this is what you need to see to calibrate,
make sure you're going to be able
to detect flow in the synovium if it's there
and you do that by this fingertip calibration
and you adjust your pulse repetition frequency
until you can see this turning up the gain
is not the way to do it.
'cause all that's going to do is increase the noise
and your signal to noise ratio does not change.
All right, so that's the vol, our fingertip calibration.
Okay, so once again we're going to rely,
and I'm putting my other hand in here purposely
because we're going to do our physical exam first.
This is the thumb carpal metacarpal joint,
the the thumb or the first CMC joint.
So here is the metacarpal bone. The carpal bones are here.
So this is the carpal metacarpal joint of the thumb.
This joint is the most commonly affected joint
by osteoarthritis in the hand.
And that's because human beings have this thing called a
thumb that allows us to do all sorts
of wonderful manipulations.
And we use this joint a lot.
When it gets to look like this,
then you're going to start seeing uglier CMC joints.
But let's look at a normal one on physical exam.
Hers is normal. There's lot, there's lots
of angles that you can use to look at this particular joint
and even younger folks are going to have a little bit
of degenerative change here.
As you can see there's a bone spur sticking up off the,
off the joint right there.
And that's, you're probably not going to see
that in 18 year olds,
but anybody past the age of 25 is going to have some degree
of degenerative change in this joint.
There's no fluid in the joint but,
and you, you've got to make sure you've got the right joint.
So you grab the metacarpal bone here and you move it.
Okay, we got the right joint.
And so that's the metacarpal bone, that's the
the thumb CMC joint.
Now you can look at it from kind
of the dorsal lateral approach.
You can also remember now that this is the snuff box.
The radial artery has already dived
deeply and has now traveled towards the dorsum of the hand.
So when you come around here and look at the joint
and you're fixing on injecting it,
remember the radial artery's already out of your way here,
it's already gone into the snuff box.
So we can look and at least
think about doing an injection here without worrying
about the radial artery.
Obviously there are anatomic variants
and you always want to check to make sure your needle path,
your proposed needle path does not contain any
doppler positive structure so to speak.
Okay, so let's look at this MCMC joint here
from a different angle,
grab the metacarpal and move it.
Alright, we got the right joint.
It's, it's kind of it, it's, it's sometimes easy
to get the wrong joint on on your screen
and you have to make sure you got the right one.
Just move them metacarpal bone.
So here's a more lar look at that joint
and if we just have her supinate even more
now we're going to need to increase our depth a little bit.
I've got the right joint
'cause I'm moving the metacarpal bone as you can see.
And so this is another look
at that particular joint.
So there's all sorts of approaches to injecting this joint.
And when I say injecting it, one of the techniques we use
to at least temporarily relieve
pain in this joint is
steroid injections into it.
Now I want you to notice here, if I go too far
to the ulnar aspect of the palm
and I think I'm still looking at the CMC joint,
I'm now moving the CMC joint,
but I don't see any movement on the screen.
The reason is I'm not looking at the
CMC joint on the screen.
I'm too far ulnar to the CMC joint
and I'm looking at a different joint.
So if I go back a little more radial, okay,
now I'm looking at the right joint because it's moving.
So you always have to make that check.
And if you're going to contemplate injecting this,
always put your transducer along the proposed needle path,
turn on your doppler, move it so that you're going to,
you're going to go from your needle entrance
all the way until here's the joint.
So you, you, you, you, whether you're coming from the right
to the left or the left to the right,
always move your your doppler box
along your proposed needle path just to make sure
that you don't have any vascular structure in the way.
The palmar aspect of this
MCP joint here is
where you're going to find your A one pulley on
all five digits.
And so that's important when you've got trigger fingers.
And the thumb is difficult
because just of the way the thumb is angulated
and one of the tricks I use when I'm trying to inject this
because the thumb is angled this way,
I often will put the patient in a supine position,
have them ex as long as their shoulder can tolerate it
and have them extend ab duck the shoulder
and put their hand over their head.
This exposes the palmar aspect
of the thumb at an angle such that you can
much more easily inject that a one pulley.
So just to keep it simple,
let's look at an A one pulley on a on one
of the other joints.
So obviously this is on the vola aspect or the palmar aspect
and trigger digits are extremely common.
They go along with metabolic syndrome type two diabetes.
They also tend to occur much more commonly in patients
with carpal tunnel.
So here we have the proximal on the right again
and the, you'll see now as I move
the flexor tendon,
it is going to go back and forth.
Now in this case we don't have an abnormal A one pulley.
The A one pulley is
traditionally thought to be hypoechoic
with the newer transducers
and the more high frequency capabilities
you could actually see the FIS
within the fibro cartilaginous A one pulley.
And let me now go
to the arrow again.
Here's my arrow. So here is the metacarpal head,
the A one pulley is right there.
This is all subq tissue here.
The A one pulley actually starts anatomically,
even though you can't see it, the A one pulley starts kind
of at the head net junction of the metacarpal
bone and extends all the way
to the head net junction of the proximal phalanx.
So that's the actual extent of that A one pulley.
You generally can't see it throughout that distance,
but that is the anatomic extent of it.
So what happens is when that gets thickened, you can,
you can, you can still move the tendon
but it's, it's going to be snapping
and you will often see a thickening of that, a one pulley.
I always then check it in transverse view as well.
So you can tell
because there's no bone, I'm over the MCP joint now
as I move there's the metacarpal
head and the A one pulley is
actually part of that.
It, it's actually visible here.
So if you look here, you see
a halo of ana ana coic area
that is an artifact from refraction.
What's up here is actually the pulling, it's not part
of the tendon, it's just superficial to the tendon sheath.
So this layer here, right there contains
the tendon sheath.
Superficial to that is the A one pulley, which is, is,
IM almost impossible to distinguish that
with most transducers.
Whenever you're going to inject that, you want
to do it in the long axis and,
and your target
is going to be
pretty much right there.
So if you want, remember the pulley is superficial
to the tendon sheath.
If you put your needle tip right there, then
what you do is you switch to the transverse view
and make sure that your needle tip,
which should be a bright dot, appears approximately there.
And then you start injecting a little bit.
And what you want to see in the short view
is you want to see fluid flowing around the tendon
in the long view.
You want to see the fluid
coursing along the
long axis of the tendon.
So the fluid is going to go that way.
And that way if you're in the right plane
and sometimes you may need to withdraw that needle,
you know, 200 microns in order
to find the right plane.
So you by apply a little bit of pressure
and what'll happen when you reach the right plane is
suddenly you'll feel a release of the pressure
and you'll see the fluid flowing.
Now in some instances, people with really severe
a one pulley thickening, that may not happen
because it's, you may have to put a lot
of pressure in order to pop that open.
So now those are difficult cases.
- All right, thank you Dr. Malone.
That concludes our, our live scan.
We really appreciate your,
and just the participation overall, your a wealth
of knowledge
and experience in this is, it's really unmatched
and we appreciate your, your attention to detail
and I know throughout the whole country there are
countless beginners in rheumatology
and other specialties that have, that have learned from you
and benefited from your teaching
and including myself over the years.
So I just want to take this second to thank you so much
for your time and efforts and,
and also just your partnership here
with your students both online and in person.
So Chris,
I I think you've probably got the questions queued up
if anybody has any.
If not, now's the time to queue up your questions
and Chris will moderate.
I can also use this time to, to kind
of scan in the background I've got our ultra high frequency
46 to 20 megahertz transducer
and I just kind of planned on picking up where we left off
on that live demo while we take questions.
So I'll just hit on freeze on the system here
and we've got our A one pulley up
and Dr. Malone if you'd like to add anything,
feel free to chime in.
So here I've got that I'm on digit three.
I kind of like scanning the third digit
'cause everything is nice and in line when you're on the
second digit, the tendons are a little off center maybe
that just drives my OCDA little off, you know,
if I'm over here, see
how the second digit tendons are slightly medial or ulnar.
But if you go to the third, everything's nice
and in the middle it's easy to train on.
Everything's where it should be.
But here we are on two.
- Just want to reiterate for questions.
If you're on the zoom stream,
you can put those questions into the q
and a box on the bottom or the side of your screen.
And if you're on one of your other streams,
you can just go ahead and put your question in the chat box
and that'll get forwarded over to us
and I'll make sure that we ask that for
- You.
Perfect, thanks Chris. And we've got more hand content next
week we have the advanced hands, so don't forget
that QR code gets you registered for all of them
and if you haven't hit that button, go for it.
Just kind of going through the same structures.
Dr. Malone, did we flip it around for consistency?
I'll put right side of the screen.
Proximal in this case is what we did
during the, the live demo.
And Dr. Malone, if there's anything that you want me
to point out with the arrow, I'm happy to be your, your
surrogate sonographer here
and here we've got that distal metacarpal notch.
I just want to confirm we can hear Dr. Malone.
I'm not sure if he's talking.
- Yes, yes, I'm here.
- Perfect. Okay, great. Let me turn the game down.
Zoom has that pretty hot. Might be my software too.
But you know, one,
one question we get a lot in rheumatology I think is
a learning curve, Dr. Malone, what would you recommend
people brace themselves for
and what's a good starting point?
You know, there's a lot of specialists on the call who maybe
take a rotation, rheumatology,
they might follow somebody like you and,
and pick pick up tips
and tricks to point out arthritis, you know, say we've got
rehab physiatry on the call
or we've got family medicine and
and sports medicine on the call.
You know, where, where,
where do you recommend they start their learning path when
it comes to rheumatology
and just picking out something that's not a sports injury
or maybe just swelling soft tissue masses
turn out to be synovitis.
You know, where do you, where do you like? Well I think
- I, I, my advice would be to know
what normal looks like first.
So pick up a transducer, scan yourself,
scan your patients who don't have any abnormality
of their finger joints
because there are subtle differences
amongst different individuals that are normal.
So you want to get some feel for
what the normal joints look like.
And then you should
scan people who have a known diagnosis.
So for example, if you're in a rheumatology rotation
and there's a rheumatoid arthritis patient
that comes in who's not well controlled,
the rheumatoid arthritis is not well controlled.
Those findings that we went through
of looking at the dorsal proximal region
of the finger joints and looking for fluid
and then turning the doppler on to look for hyperemia
of the synovium is very instructive to get an idea
of what a rheumatoid or an inflamed joint looks like.
So yeah, looking at the normal first is, is very helpful.
And then getting somebody with a known diagnosis so
that you know what you're looking at.
- Nice, excellent.
And I know this was focused on the hand,
but what are some other body parts that you would want to
kind of check your work for?
If you find something, I don't know,
that might be a question of inflammation.
Is there other other places in the body
that you would go double check
and say, yeah, that's probably systematic or,
or maybe this is just a, a one-off, you know,
area of inflammation.
- Any place where there's pain
and I'm scanning a painful structure, I'm using doppler.
That can also, that can often, I should say,
that can often give you a clue as to
where the pain generator is.
And what you'll find is that it is, it's
pretty common where you,
after your physical exam, you go into the scan expecting
to see A, and you end up seeing B, C, D
or E, which is very instructive
because as, as I said, this is an extension
of the physical exam.
The physical exam has its limitations
and many of those limitations are removed
by ultrasound.
And so that applies to joints, it applies to tendons,
it applies to virtually anything in the
musculoskeletal system.
It applies even to nerves
and compression syndromes looking at the shape.
So there's virtually no limit to what you can do
with ultrasound provided you know what normal looks like
and you have some idea of what you're looking for.
- Very good. How are we doing on time, Chris?
- It looks like we're about five over right now,
but looks like we don't have any questions at the moment,
so I don't know if you want to scan another
structure in there somewhere.
- Happy to. So I was just over that flexor tendon
and I just want to point out some of that anatomy that we had.
I've got a arrow I can pull up.
So this is the distal metacarpal head, just
as a landmark I can tell that
because there's an incompressible cartilage
and then we see the palmer plate
or voler plate that was talked about.
But the neat thing about 46 megahertz is
you can see the fibers of the voler plate
horizontally on the screen.
Typically that's averaged out, it's, it's just something
that most transducers see a homogeneous pad.
But then you kind of learn that,
that these fibers have direction
and that's why oftentimes when you go long axis on it,
the Waller plate might be a black area
because it, you're just looking at a cross section
of something that's anti anti isotropic.
So pretty neat to see the real fibers.
Not to mention the pulley more shallow up here,
this level up here I can see real fibers.
Those are not the dark stripe that,
that we're always looking for now is,
has real structure to it.
So is this transducer for everybody?
You know, maybe, maybe not,
but I do think it, this will
broaden our understanding of some of the anatomy
as we use it under ultrasound
to see more detail in these layers and,
and try to find out where,
where we can learn more about finding pathology
and finding normal and differentiating these layers
that used to just be shadows.
So as transducer technology gets better
and better, our understanding of what to look
for gets better and better.
So I see people on the forefront
probably gravitating to a transducer like this to do,
you know, almost new work in anatomy so
that it can help others.
So very excited to see what something like this might do
in the rheumatology world when it comes to synovitis.
You know, I was just on the dorsal MCP joint.
Here's the PIP and that's the bowler plate of the PIP joint.
But you can see the joint capsule pulling back.
And we will cover some
of this in more detail on the advanced webinar.
But we've got, you know, not only bowler plate
and flexor tendons in layers of the flexor tendons.
If I go distally on either side, I can see superficialis
go on each side of profundus.
Profundus is now on top of superficialis
and we'll learn why next week
and talk about the various stages of transition
where these tendons switch spots.
And then you've got bowler plate, which is this cool pad.
But then what about the pad? Where does it attach?
And we've got these ligament layers
that we'll learn about next week
and we can see those really nicely with, with 46 megahertz
where they may just be a shadow on on previous transducers.
And there's a whole network of things around the joints
that we're going to see a little bit better.
Let's go palm down and back to that MCP joint.
We've got our distal metacarpal head and metacarpal notch
and then we've got all these crazy
structures on top of that.
So where does the tendon begin and end?
We've got to make it move. I'm just going to push her fingernail
down a little into the bed or have her slowly extend
and we can see her joint capsule right here
because it's normal, it's not thickened.
And as she moves we can see the extensor tendon move.
And then this is a cross-sectional sagittal band underneath.
So there's a deep sagittal band
and a superficial one also covering that next week.
So don't miss the detailed survey of the hand.
When we get into our, our advanced session next week,
we're going to delineate these layers, what's what
and what's capsule and what's not with 46 megahertz
and other traditional transducers.
So we'll, we'll kind of pick up where
46 leaves off and vice versa.
But here's the, the joint recess proximally
that Dr. Malone described in the slides.
So you can see how far back you could look
for joint effusions.
You can see how far proximally you could look
for a loose body or synovitis to swell.
So you don't want to stop looking for synovitis right
above the joint but follow that joint line.
So here's that metacarpal head.
So you know, joint capsule starts here,
folds back redundantly as Dr.
Milan mentioned. And it kind of reminds me of a knee,
you know, a knee joint without a kneecap.
So I would just put a kneecap above the joint here
and you get very similar anatomy.
- I do have a question coming in.
We have, can you show the nerves on the sides?
- Sure. I'm assuming maybe digital nerves,
although we've had questions in the past about maybe the
radials, but also in the advanced we're,
we're going to be covering neurovascular a little bit more
detailed, but say I was on the proximal side
of the hand climbing up.
I'm going to pull the hand just a little further into view.
And we wanted to trace superficial radial.
So here's, you know, that intersection syndrome proximal
to the compartments
and we've got second compartment
coming into first compartment here
and above those you can see this guy,
which on this transducer looks a lot like a vessel.
But that is the superficial radial.
And to be confident because there's
so much variable anatomy, I like to go all the way back
to the compartment level at least
and find these radial branches and then go distally
and just keep following, following.
See here it's going to split so we can see those split.
So here's a more dorsal branch, here's a more volar branch.
Branch, but these are the nerves
with this particular transducer.
And we're in the general mode.
If I go more shallow
and let the machine focus more on the nerves
and then I switch my frequency to something higher.
'cause we're in the general mode of 46 to 20,
depending on our transducer imaging depth.
We're not at the top end of the frequency just yet.
But if I wanted to hit the top end
and say have these teeny tiny ones look even more clear,
which are right here, then I would go
to resolution mode
and we'll get more
echoes there.
I'm not sure how that's coming across on zoom.
It's a little bright. There we go.
Now that I look at the screen.
So Dr. Malone, you mentioned neuropathy in
arthritis, other degenerative conditions,
DI diabetes or,
or any other factors that might make a nerve look odd.
And then you mentioned fales looking different
and changing their shape.
Where, where would you look for fassal changes
or what's the general shape you would look
for in a nerve fale versus, you know, somebody
that has some pathology?
- There is no data on that
because the use of
high frequency transducers is still too new
to correlate with, for example,
electrophysiologic studies or certain type of neuropathy.
So that how the different neuropathies appear
on these high frequency ultrasound scans.
I don't think there's any good studies on that yet.
- No, sounds exciting. Like somebody needs to pick up
that torch and pick up
where conventional imaging would leave off.
- And we do have another question coming in.
Can you comment on the MCP sagittal band as well
as the PIP radial ulnar collateral ligaments?
These are locations that are important in lupus.
- All right, so yes and no.
So I'll give you a little bit of it today,
but I also need you to join us next week
because we're going to go through this diagram first
and then scan diagram.
Scan. And we're going to go through sagittal band,
we're going to go through pulley, we're going to go
through the ligaments, the collateral ligaments
of not every joint because there's a lot of redundancy,
but we'll go over the collateral ligaments that do
stay most common.
The accessory, the primary, some
of the lesser known ligaments, the langio glenoid.
We're going to cover UCL in the thumb, which I think is most,
you know, across modalities.
You got your sports and rehab and and arthritis.
Two, you know, they're no stranger to having the UCL tear.
So we'll go over those.
But just as a teaser for next week, you know, we've got,
I stay in the third digit to practice these things
because when you get out to the fifth
and the second, the anatomy is very variable here on the
locations of the fifth digits.
Extensor tendons are a bit frustrating.
They don't look exactly like anatomy diagrams.
So you could almost call next week's webinar the variable
hand, but we'll just keep it at advance.
But if you train and practice the anatomy on three
and four, it'll stay pretty straightforward to
what a textbook looks like.
But you'll see the difference here.
Just as a pitfall, you have one nice extensor tendon
on three, but watch when I go over here to two, when I go
to two, we have two extensor tendons
because there's communist
and indices right next to each other
and they have variation.
Do I have more than one head
or band on, in this case, the one that's more radial would
BEUs I think.
And indices I think is this one that is more owner.
We could check our work just by
going on back to figure out which is which.
Yes. So here goes indices deep to the rest
of the common extensors.
But if you're trying to practice sagittal bands on the
second digit, it's a bit trickier
because it envelops so much more tendon
that goes more medial and lateral.
And then the, this whole halo looking thing
around the tendon is sagittal band.
There's a deep when superficial.
But next week we're going to trace that out on each side of
what we can reach because there's limitations
between these other digits.
And then the same for the PIP joints.
I'll tease that out just a little bit, just
for fun while we're catching some questions.
But you know, we're going to go over the central flip.
Let me drop my frequency a bit.
While the gel penetrates the skin
dry skin at 46 megahertz will kill your
ultrasound beam straight out of the gate.
So as gel soaks into the skin, the beam gets a little bit,
it propagates better through moisture, then attenuates
through something dry.
But we're going to do dynamic exams,
like I can see the central slip.
There's also more of a fascial fiber that goes on top
and I'm just moving the fingernail
and you can see I drag that whole layer
and then the collateral ligaments on the sides.
Next week we'll go over the primary
and we will go almost short access to go over the accessory.
The accessory will wrap around
and become a big part
of the pulley complex with the voler plate.
So good, good question. Good teasers for next week.
We do want you to, to join us
where we focus more on those topics.
We've teased a few of these out each time,
but you know, I think this one we've gone over the longest,
but I do want to be respectful of everybody's time.
But I do want to express our tremendous gratitude
to Dr. Malone and his time and efforts and expertise
and just his, his general overall impact in the rheumatology
ultrasound field.
It has not gone unnoticed.
I think Dr. Malone, you've been doing musculoskeletal,
rheumatology, ultrasound for 20 years now at least.
- Yeah, that's right.
- Absolutely. Yeah, we'd love
to thank you guys for joining us.
As Daniel said, we are quite a bit over time now.
But thank you guys for staying around
and asking questions Right now.
On the screen you can see our QR code to go to the
Sono site webinars page,
and we will have that advanced hand webinar on October 7th.
So we look forward to you guys joining us then.
And once again, thank you so much to Daniel
and Dr. Malone for being here and this amazing presentation.
We really went over a lot of stuff today, so thank you guys
so much for being here.
- All right, my pleasure. - Thank
- You everybody.
Ultrasound enables the detailed assessment of rheumatoid arthritis and osteoarthritis, now enhanced with Sonosite’s new ultra-high frequency transducer: UHF 46-20 MHz. Join Daniel Shelton and Dr. Daniel Malone for Part 3 of the Diagnostic Hand Ultrasound Series: ‘Arthritic Hand’ to distinguish between rheumatoid arthritis and osteoarthritis findings. This webinar will also review the critical role of color power doppler for confirming synovitis and discover the benefits of ultra-high frequency for enhanced diagnostic precision.
What You'll Learn
- Identify common landmarks for evaluating rheumatoid arthritis and osteoarthritis.
- Differentiate synovitis associated with rheumatoid arthritis from joint effusions that are more common with osteoarthritis.
- Discuss the role of color power doppler when confirming synovitis.
- Discover the benefits of ultra-high frequency when diagnosing these conditions.
Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.
President, Wisconsin Rheumatology Association
Dr. Dan Malone teaches diagnostic and interventional Musculoskeletal ultrasound all over the nation, earning his MD from the University of Illinois Abraham Lincoln School of Medicine in Chicago, with a fellowship in basic scientific immunology research at the National Institutes of Health in Bethesda, MD. He was on the faculty of the University of Wisconsin-Madison for 23 years before joining the private sector. He is current president of the Wisconsin Rheumatology Association and chair of the Musculoskeletal Ultrasound committee for Inteleos ARDMS/APCA.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.