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Oct ultrasound case of the month

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  • 1. Ultrasound Case of the Month October 2013
  • 2. 61 year old male with right shoulder pain and limited range of motion
  • 3. Grayscale Images of the Infraspinatus
  • 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. Diagnosis: Calcific Tendinitis
  • 6. Calcium Hydroxyapatite Deposition • Primary/Idiopathic • Secondary • End stage renal disease • Collagen vascular disease • Vitamin D intoxication • Tumoral calcinosis
  • 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. 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. Calcific Tendinitis: Case Points Pathogenesis • Three phases (Morley et al) 1. Silent 2. Mechanical 3. Adhesive Periarthritis
  • 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. Calcific Tendinitis: US • Calcium hydroxyapatite deposition looks like calcium anywhere else in the body: • Anechoic • Hyperechoic shadow • Posterior acoustic shadow
  • 12. Calcific Tendinitis : Radiographs AP view of the left shoulder Transscapular Y view (different patient)
  • 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. Calcific Tendinitis: MRI • Hypointense on T1 and T2 Oblique sagittal proton density and FS T2 weighted sequences through the left shoulder
  • 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. 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. Calcific Tendinitis: MRI Oblique coronal proton density and T2 fat suppressed
  • 18. Calcific Tendinitis: MRI Oblique sagittal proton density and T2 fat suppressed
  • 19. Calcific Tendinitis: MRI • The previously seen calcium hydroxyapatite deposit has eroded into the humeral head • Marked surrounding bone marrow edema
  • 20. Calcific Tendinitis : Treatment • Conservative – NSAIDs – Oral steroids – Image guided steroid/anesthetic injection – Image guided aspiration/lavage
  • 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. Calcific Tendinitis : Treatment The deposit is then lavaged with 2% lidocaine (A: injection, B: aspiration) A B
  • 23. Calcific Tendinitis : Treatment
  • 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. 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. 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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