Transcript ULTRASOUND OF MUSCULOSKELETAL INFECTIONS Mouna …

ULTRASOUND OF MUSCULOSKELETAL INFECTIONS
MA KAMMOUN, M CHELLI BOUAZIZ, A MAALEJ, M F LADEB
Department of Radiology. Institut M T Kassab d’orthopédie.
Ksar Said. Tunisia
MUSCULOSKELETAL : MK 23
INTRODUCTION
• Musculoskeletal infections are commonly encountered in
clinical practice in children and adult patients
• Radiographs remain the first imaging modality to perform
in these conditions
• Ultrasound (US) may be used either as the primary
imaging technique or as an adjunct to radiography,
computed tomography (CT), magnetic resonance imaging
(MRI) and nuclear medicine studies
OSTEOMYELITIS
Acute osteomyelitis
•Daily US examination allows an early detection of subperiosteal
abcess thus indicating surgical treatment (protocol of Tunis).
•Clinical and US differential diagnosis is sometimes difficult with
sickle cell anemia vaso-occusive crisis and subperiosteal
haematoma.
Acute osteomyelitis: subperiosteal abcess
of the femur is well assessed with US
Acute osteomyelitis: subperiosteal abcess of
the tibia is well assessed with US
Vaso-occlusive crisis. US shows a
subperiosteal haematoma of the tibia
Vaso-occlusive crisis. US shows a
subperiosteal haematoma
OSTEOMYELITIS
Chronic osteomyelitis
• Soft tissue modifications and /or Juxtacortical collections are
assessed with US in acute reactivation of chronic osteomyelitis.
• Fistula , soft tissue sequestra and cortical bone modifications
are also well assessed with US
*
Chronic osteomyelitis reactivation: Juxtacortical abcess with sequestrum
*
Chronic osteomyelitis reactivation:
Juxtacortical abcess with a fistula.(*)
Reactivation of a chronic osteomyelitis. US shows cortical
bone irregularities and calcifiactions with a soft tissue
abcess
ARTHRITIS
• In acute arthritis, US shows a joint effusion with or
without synovial thickening and local hyperhemia.
• Bone abnormalities such as periosteal new bone
formation or perichondral erosions are also well
assessed by US
ARTHRITIS
• Chronic arthritis may show a similar appearance
• A local amyotrophy around the joint may be
observed. Several ultrasonographic signs may help to
identify specific infections
ARTHRITIS
• The importance of synovial thickening and the
presence of thin calcifications into the synovium
suggests a tuberculous origin whereas a multicystic
appearance is characteristic of echinococcosis
Acute knee arthritis. US shows a joint effusion with
synovial thickening
Acute arthritis of the elbow. US Shows a joint
effusion without synovial thickening
Acute arthritis of the knee. US shows an important
synovial thickening with joint effusion and local
hyperhemia.
*
**
Osteo arthritis of the first metatarsophlangeal joint. Bone
abnormalities such as periosteal new bone formation (*) and
perichondral bone erosion (**) are easily assessed by US
*
Tuberculous arthritis of the
knee. Note the importance
of the synovial thickening
and the fine synovial
calcification(*).
Echinococcosis of the iliac bone.
US
shows
a
characteristic
multicystic appearance in the soft
tissues.
INFECTIOUS CELLULITIS
• Infection of the skin and subcutaneous tissue
• Clinical diagnosis often obvious:
• Sudden onset of local and general
inflammatory closet "orange peel“
• Alteration of general state, fever, ganglia
INFECTIOUS CELLULITIS
IMAGING
• Radiographs: nonspecific
• Ultrasound: abscess
Diffuse thickening of the skin
"dissected appearance" of subcutaneous fat lobules
Hyperemia at color Doppler
• CT / MRI:
Infiltration of subcutaneous fat
Hypo T1, T2 Hyper without mass effect
Enhancement after contrast injection
+ / - Edema of the fascia and adjacent muscles
*
Radiographs showing thikening
of sucutaneous fat (*).
US: soft tissue thickening
and Doppler hyperhaemia
soft tissue cellulitis: US
shows
"dissected
appearance"
of
subcutaneous fat lobules
PHLEGMON AND PYOMYOSITIS
• Pyomyositis: muscle abscess
• Phlegmon: inflammatory infiltration of the
muscle not collected before the collected stage
PHLEGMON AND PYOMYOSITIS
CLINICAL PRESENTATION
• Pain
• Muscle induration
• History of local trauma: from 22 to 67%
• A single muscle group is usually affected
• Careful analysis of adjacent bones and joints to confirm
the muscular origin of the infection
PHLEGMON AND PYOMYOSITIS
IMAGING
• Radiographs : of little use
• Ultrasound:
Increased muscle volume
hypoechoic septa
Evolution towards
the abscess with hypoechoic center + / - standard liquid
or thin walls
Echogenic wall + / - thick that may contain calcifications
Imaging can guide the puncture
Pyomyositis of the thigh: US shows muscle thickening, heterogenous
appearance and colour Doppler hyperhemia.
Pyo-myositis in 33 years old man. US shows global thikening of biceps muscle and
presence of liquid collection (abcess) into the muscle.
SEPTIC BURSITIS
• Clinical presentation: local inflammatory syndrome
Fever: 40% of cases
• Germ: staph aureus
• X-rays + CT: Swelling of the bursa
• Ultrasound: Thickening of the bursa wall, echogenic content , Doppler
hyperemia
• MRI: staging
Septic bursitis: Ultrasound shows
thickening of the subacromial subdeltoid
bursa wall with color Doppler
hyperemia
and fluid collection
SEPTIC TENOSYNOVITIS
• Often by inoculation
• Staph aureus, tuberculosis
• Fingers and toes flexors
• Radiographs: eliminate arthritis or osteitis
• Ultrasound: thickening of tendon sheath + / - effusion, Doppler hyperemia
• MRI: thickening of tendon sheath, enhancement after contrast injection
Tenosynovitis: US shows thickening of the
tendon sheath + / - effusion, Doppler
hyperhemia
Note also the presence of little abcesses into
the synovial sheath
CONCLUSION
• Ultrasound is very performant in the diagnosis and follow up
of musculoskeletal infections.
• It allows to:
• differentiate infection from tumors or non-infective
inflammatory conditions with similar clinical presentation
• localize the site and extent of infection
• guide drainage or biopsy