Oct ultrasound case of the month

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Oct ultrasound case of the month

  1. 1. Ultrasound Case of the Month October 2013
  2. 2. 61 year old male with right shoulder pain and limited range of motion
  3. 3. Grayscale Images of the Infraspinatus
  4. 4. Grayscale Images of the Infraspinatus Calipers denote a hypoechoic focus with a hyperechoic rim and posterior acoustic shadow within the infraspinatus tendon representing calcium hydroxyapatite deposition
  5. 5. Diagnosis: Calcific Tendinitis
  6. 6. Calcium Hydroxyapatite Deposition • Primary/Idiopathic • Secondary • End stage renal disease • Collagen vascular disease • Vitamin D intoxication • Tumoral calcinosis
  7. 7. Calcific Tendinitis: Case Points Pathogenesis • Unknown • Hypotheses include: • Abnormal pressure and compression (Codman) • Decreased localized vascularity and pre-existing tissue degeneration (Sandstrom) • Local changes in pH and secondary necrosis (Pederson & Key) • Trauma (Gondos)
  8. 8. Calcific Tendinitis: Case Points Predominantly affects • 40-70 year olds, men slightly more than women • 50% in the shoulder, though deposition can be found at nearly every joint Clinical Presentation Severe pain, tenderness, erythema, limited range of motion
  9. 9. Calcific Tendinitis: Case Points Pathogenesis • Three phases (Morley et al) 1. Silent 2. Mechanical 3. Adhesive Periarthritis
  10. 10. Calcific Tendinitis: Case Points 1. Silent phase - Calcium within the substance of the tendon itself - Minimal/no symptoms 2. Mechanical - Enlargement of the deposits - Deposit becomes liquified (may no longer see the deposit on radiographs)  increased pressure/bursitis  impingement-like symptoms - Recurrent bursitis leads to eventual rupture of the deposit 3. Adhesive Periarthritis - Variable sized calcium deposits, destructive changes - Worsened pain, limited range of motion
  11. 11. Calcific Tendinitis: US • Calcium hydroxyapatite deposition looks like calcium anywhere else in the body: • Anechoic • Hyperechoic shadow • Posterior acoustic shadow
  12. 12. Calcific Tendinitis : Radiographs AP view of the left shoulder Transscapular Y view (different patient)
  13. 13. Calcific Tendinitis : Radiographs • Well-defined calcium deposit within the supraspinatus tendon • Most deposits are ovoid, although they may be linear or triangular • This radiograph was taken during the silent / first phase of calcific tendinitis
  14. 14. Calcific Tendinitis: MRI • Hypointense on T1 and T2 Oblique sagittal proton density and FS T2 weighted sequences through the left shoulder
  15. 15. Calcific Tendinitis: MRI Sagittal and axial T2 fat suppressed images in the same patient demonstrate focal calcium hydroxyapatite deposition within the supraspinatus in the silent/first phase of calcific tendinitis
  16. 16. Calcific Tendinitis: MRI • No intervention was performed and the patient’s symptoms continued to worsen • The following images are from the MRI on the same patient performed 8 months later
  17. 17. Calcific Tendinitis: MRI Oblique coronal proton density and T2 fat suppressed
  18. 18. Calcific Tendinitis: MRI Oblique sagittal proton density and T2 fat suppressed
  19. 19. Calcific Tendinitis: MRI • The previously seen calcium hydroxyapatite deposit has eroded into the humeral head • Marked surrounding bone marrow edema
  20. 20. Calcific Tendinitis : Treatment • Conservative – NSAIDs – Oral steroids – Image guided steroid/anesthetic injection – Image guided aspiration/lavage
  21. 21. Calcific Tendinitis : Treatment Utilizing ultrasound guidance, a needle is advanced into the deposit and a small volume of lidocaine is injected around and within the deposit
  22. 22. Calcific Tendinitis : Treatment The deposit is then lavaged with 2% lidocaine (A: injection, B: aspiration) A B
  23. 23. Calcific Tendinitis : Treatment
  24. 24. Calcific Tendinitis : Treatment Once the deposit is aspirated as much as possible, a solution of anesthetic and steroid is injected into the region and the needle is withdrawn
  25. 25. Calcific Tendinitis : Treatment Syringes a) immediately and b) delayed after lavage with lidocaine. The calcified material has layered onto the bottom of the syringe over time. (a) (b)
  26. 26. References • Aina R, Cardinal E, Bureau NJ, et al. Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique. Radiology 2001; 221:455–461. • Flemming D, Murphey M, Shkitka K, et al. Osseous involvement in calcific tendonitis: a retrospective review of 50 cases. AJR 2003; 181:965–972. • Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics 1990; 10(6):1031-48. • Serafini G, Sconfienza LM, Lacelli F, et al. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle US- guided percutaneous treatment-nonrandomized controlled trial. Radiology 2009; 157–164

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