A brief review of the uses of musculoskeletal ultrasound in both diagnosis and intervention of musculoskeletal manifestations in nephrology

1. Applications Of
Musculoskeletal
Ultrasound In
Nephrology
Samar Tharwat Radwan
Lecturer of Internal Medicine
(Rheumatology & Immunology)
Musculoskeletal Ultrasound –EULAR
Mansoura University

2. Introduction
• Chronic kidney disease and hemodialysis
is becoming more prevalent in the 21st
century.
• Musculoskeletal manifestations are
common among these patients.
• These manifestations affect the quality of
life in these patients

3. Diagnosis
• Serum biomarkers
• Bone abnormalities
• Imaging:
Conventional radiology
MRI
Musculoskeletal Ultrasound

4. Conventional
radiology
Advantages :
• Low cost
• Easy access
• Valid
• Bone evaluation
Disadvantages :
• Ionizing radiation
• No access to soft tissues

5. MRI
Advantages :
• The gold standard in evaluating joint pathology
Disadvantages :
• Expensive
• Limited availability
• Lengthy time
• Claustrophobia

6. Musculoskeletal
Ultrasound
Advantages:
• No radiation
• Real time examination
• Dynamic (motion assessment)
• Sonopalpation for tenderness
Disadvantages:
• Poor penetration through bone
• Dependent on operator skill
• Takes time

7. Musculoskeletal Ultrasound Echogenecity

8. Any structure should be evaluated in both longitudinal and transverse scan

9. Applications Of Musculoskeletal Ultrasound In Nephrology
Diagnosis
• Synovial proliferation
• Detection of Bone Erosion
• Tendons
• Enthesitis
• Cartilage
• Peripheral nerves
• Muscles
• Bursitis
• Tumoral calcification
• Dialysis related amyloidosis
• Bone fracture
• Infection
Interventional Musculoskeletal Ultrasound

10. Synovial proliferation
US ankle joint:
Longitudinal scan
Normal synovial lining Synovial hypertrophy:
swelling of the
synovial lining
Synovitis: hyperemia
as demonstrated by
Doppler

11. Arthritis
Gout
Pseudogout
Septic

12. Detection of
Bone Erosion

13. Metacarpophalangeal
joint :longitudinal scan
Bone erosion US :
cortical break
Bone erosion :X-Ray

14. Ultrasound is
more sensitive
than
radiography in
detection of
bone erosion
A longitudinal section through a metacarpal head is
compared with a radiograph, which appears normal and
shows no evidence of a cortical break

15. Haemodialysis-related
erosive arthropathy
• Small joints of the hands
• AE : amyloidosis, hyperparathyroidism ,
CPPD , and metabolic bone disease
• Periarticular cystic/erosive changes

16. Tendons

17. Longitudinal scan: parallel, fine, fibrillar pattern
Short axis : hyperechoic pattern of
tendons, with scattered spotty echoes

18. Tenosynovitis : synovial hypertrophy or anechoic fluid
within the tendon sheath (13% of HD patients)

19. Tendinosis
• Degenerative tendon abnormality
• The tendon appears thick ,swollen
, hypoechoic , with loss of fibrillar
pattern
HD patients:
• 80% supraspinatus tendon
• 67.9% Achilles tendon

20. Calcific
Tendinosis
• Calcium hydroxyapatite
• Hyperechoic
• With or without an
acoustic shadow

21. Tendon Tears
Partial tear
an anechoic focus inside the tendon
no signs of retraction
Full-thickness tear
discontinuity of tendon
retraction in dynamic imaging

22. Spontaneous
tendon
rupture in HD
patients
Hyperparathyroidism
Chronic acidosis
Uremic toxin
Malnutrition
B2-amyloidosis

23. Quadriceps tendon rupture
Quadriceps
femoris: long axis
Normal quadriceps
tendon
Ruptured tendon
and hematoma

24. Tricepes tendon rupture
Triceps evaluation
(long axis)
Triceps muscle
and tendon
Complete tendon
disruption

25. Achilles tendon rupture
Achilles tendon
long axis
Normal US Complete tear of
Achilles tendon

26. Enthesitis

27. Enthesis
the site of
insertion of
tendon , ligament,
fascia, or joint
capsule into the
bone

28. Enthesitis
• Hypoechogenicity
• Increased thickness of the tendon
• Calcifications
• Enthesophyte
• Erosion
• Cortical irregularities

29. Cartilage

30. Normal cartilage Cartilage US
knee
Hypoechoic
hyaline cartilage

31. Loss of
cartilage :
osteoarthritis
Diffuse cartilage thinning of the femoral condyles

32. Calcium Pyrophosphate Dihydrate Disease
CPPD crystals typically lie within the hyaline cartilage layer.
Small, hyperechoic spots that are isolated or that form larger, confluent deposits.

33. Gout
Snowstorm:
MSU microcrystals float
in the joint cavity
Double
contour of the hyaline
cartilage
A large intraarticular hard
tophus

34. Peripheral Nerves

35. Normal Nerve :multiple, rounded nerve
fascicles of different sizes that are made of
tightly packed nerve fibers and embedded
in the surrounding epineurium
Short axis nerve :multiple hypoechoic
fascicles in a hyperechoic internal
epineurium and hyperechoic external
epineurium
Long-axis ultrasound image of the median
nerve at the wrist shows the nerve
fascicles (closed arrowheads), internal
epineurium (open arrowheads), and
external epineurium (arrows)

36. Peripheral neuropathy of
the limbs has been reported
in 50%–60% of patients with
end stage renal disease
Diagnosed mainly by
electrophysiological studies

37. Carpal tunnel syndrome is common in CKD, with a
prevalence of 5–30%,especially in HD patients
(amyloidodis)
US :Median nerve Normal median nerve Short axis: hypoechoic
nerve swelling
Long axis: hypoechoic
nerve swelling

38. Muscles

39. Longitudinal scan Longitudinal scan:a feather-like
appearance:muscle fibers has
oblique orientation in relation
to the tendon
Transverse scan Transverse scan : perimysium
is seen as white dots

40. RFCSA evaluation by CT (A) and US
CLINICS 2018;73:e39

41. Bursitis

42. Olecranon bursitis
Dialysis elbow/ Uremic bursitis
• Due to repeated friction during HD practice

43. Tumoural
calcification

44. Calcium deposition in the soft tissue in periarticular location

45. Dialysis Related
Amyloidosis

46. Swelling of median N.
Loss of fascicular texture
Thickening of the rotator cuff
tendons
Tendon sheath filled with an
hypoechoic and homogeneous
material
thickness of SASD
Hypoechoic mass
around flexor tendons
Erosion of humerus
echogenic amyloid tissue
MSK manifestations due deposition of β2-microglobulin:
CTS ,flexor tenosynovitis , shoulder pain ,osteoarthropathy ,lytic bone
lesions

47. Bone fracture

48. Discontinuity of the bone cortex with step-off deformity

49. Infection

50. Cellulitis
Confluent hypoechoic fluid channels

51. Septic arthritis
Mixed echogenicity distention of the radiocarpal and
midcarpal dorsal joint recesses

52. Septic tenosynovitis
Flexor tendon :hypoechoic synovial
hypertrophy (arrows) with hyperemia

53. Interventional
Musculoskeletal
Ultrasound

54. JOINT PROCEDURES
Indications:
•Aspiration
•Injection
•Synovial biopsy

55. Tendon pathology

56. Bursitis

57. Median nerve hydrodissection

58. Musculoskeletal Ultrasound is like a stethoscope for the musculoskeletal system