The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development.

OBJECTIVES: Tenosynovitis (TS) is common in early arthritis. However, the value of US-defined TS in predicting RA development is unclear. We assessed the predictive utility of US-defined TS alongside US-defined synovitis and clinical and serological variables in a prospective cohort of early arthritis patients. METHODS: One hundred and seven patients with clinically apparent synovitis of one or more joint and symptom duration ⩽3 months underwent baseline clinical, laboratory and US assessment of 19 bilateral joint sites and 16 bilateral tendon compartments. Diagnostic outcome was determined after 18 months, applying the 2010 ACR/EULAR classification criteria for RA. The predictive values of US-defined TS for persistent RA were compared with those of US-defined synovitis, clinical and serological variables. RESULTS: A total of 4066 US joint sites and 3424 US tendon compartments were included in the analysis. Forty-six patients developed persistent RA, 17 patients developed non-RA persistent disease and 44 patients had resolving disease at follow-up. US-defined TS in at least one tendon compartment at baseline was common in all groups (RA 85%, non-RA persistent disease 71% and resolving 70%). On multi-variate analysis, US-defined digit flexor TS provided independent predictive data over and above the presence of ACPA and US-defined joint synovitis. CONCLUSION: US-defined digit flexor TS provided independent predictive data for persistent RA development in patients with early arthritis. The predictive utility of this tendon site should be further assessed in a larger cohort; investigators designing imaging-based predictive algorithms for RA development should include this tendon component as a candidate variable.

Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology.

OBJECTIVE: To develop clinical guidelines for musculoskeletal ultrasound (MSKUS) referral in Europe. METHODS: Sixteen musculoskeletal radiologists from seven European countries participated in a consensus-based interactive process (Delphi method) using consecutive questionnaires and consensus procedure meetings at several European radiology meetings. The evaluation of musculoskeletal diseases was established by literature reviews, followed by consensus on clinical utility in three consensus meetings. This involved a thorough, transparent, iterative approach which including interview, questionnaire, Delphi and standard setting methodologies. European MSK radiologists with a special interest in MSKUS formed two different expert groups who worked on reaching a consensus in the first two meetings. The third meeting resolved questions that did not achieve a consensus level of 67% using the first two questionnaires. RESULTS: On expert consensus, the use of MSKUS is indicated to detect joint synovitis, fluid and septic effusion for potential aspiration, and poorly indicated to detect loose bodies. Recommendations for most appropriate use of musculoskeletal ultrasound are reported in six areas relevant to musculoskeletal ultrasound: hand/wrist, elbow, shoulder, hip, knee and ankle/foot. CONCLUSION: A comprehensive evidence-based, expert consensus-defined educational framework on clinical ultrsound is presented. This should facilitate referrals for this important imaging technique throughout Europe. KEY POINTS: Musculoskeletal ultrasound is indicated for detecting joint synovitis, effusions and fluid collections. • Musculoskeletal ultrasound is poor at detecting loose bodies. • Musculoskeletal ultrasound is relevant for most joints.

Imaging of the carpal tunnel.

Most patients with symptoms related to the carpal tunnel have idiopathic median nerve compression. Imaging has little role in the care of most cases because steroid injection, therapeutic ultrasound, and surgery have established roles. However, cases with atypical presentation, mass lesions, synovitis, or failed carpal tunnel surgery will benefit from imaging. In this article we review the anatomy of the carpal tunnel, the diseases affecting this region, and then discuss the use of conventional radiographs, computed tomography, ultrasound, and magnetic resonance imaging (MRI), outlining the strengths and weaknesses of each method while listing the signs of disease. We conclude that both ultrasound examination and MRI are powerful and often complementary techniques.

Lumbar nerve root blocks using MRI - the effectiveness and safety of ultrasound/MRI fusion image guidance.

OBJECTIVE: To compare the outcome of nerve root injection guided by ultrasound/MRI fusion with radiofrequency needle tracking (eTRAX©) and the same procedure undertaken by fluoroscopic guidance. METHODS: This is a retrospective audit of anonymised clinical records from before and after a change in the imaging technique used to perform nerve root blocks.We studied 181 consecutive patients who had undergone a nerve root block, the first 124 guided by fluoroscopic technique and the next 57 guided by ultrasound/MRI fusion with radiofrequency needle guidance.Using pain diaries, we reviewed the outcome scores at 24 h and 2 weeks. We recorded the use of analgesia, the patient's satisfaction, complications and the duration of the procedures. RESULTS: Completed pain diaries were returned by 61% in the fluoroscopy group and 67% in the fusion imaging group.The visual analogue pain score was reduced at 24 h by 3.29 [standard deviation (SD) 2.35] for the fluoroscopy group and by 3.69 (SD 2.58) in the fusion group (p 0.399).At two weeks the pain reduction was 3.27 (SD 2.57) for the fluoroscopic group and 4.21 (SD 2.95) for the fusion group (p 0.083). There was no statistically significant difference between the groups.The patient's satisfaction scores were similar for both groups.The procedure by the two guidance methods took a similar time to perform.There were no serious complications in either group. One patient in the fusion-guided nerve root block group experienced paraesthesia in the nerve distribution for 2 h. CONCLUSION: Ultrasound/MRI fusion imaging with needle tracking is an effective alternative to fluoroscopic image-guided injection. ADVANCES IN KNOWLEDGE: Fusion imaging guidance provides the same outcome as fluoroscopic guidance.Fusion imaging guidance avoids the need for ionising radiation.

Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis.

OBJECTIVES: Early therapy improves outcomes in rheumatoid arthritis (RA). It is therefore important to improve predictive algorithms for RA in early disease. This study evaluated musculoskeletal ultrasound, a sensitive tool for the detection of synovitis and erosions, as a predictor of outcome in very early synovitis. METHODS: 58 patients with clinically apparent synovitis of at least one joint and symptom duration of ≤3 months underwent clinical, laboratory, radiographic and 38 joint ultrasound assessments and were followed prospectively for 18 months, determining outcome by 1987 American College of Rheumatology (ACR) and 2010 ACR/European League Against Rheumatism criteria. Sensitivity and specificity for 1987 RA criteria were determined for ultrasound variables and logistic regression models were then fitted to evaluate predictive ability over and above the Leiden rule. RESULTS: 16 patients resolved, 13 developed non-RA persistent disease and 29 developed RA by 1987 criteria. Ultrasound demonstrated subclinical wrist, elbow, knee, ankle and metatarsophalangeal joint involvement in patients developing RA. Large joint and proximal interphalangeal joint ultrasound variables had poor predictive ability, whereas ultrasound erosions lacked specificity. Regression analysis demonstrated that greyscale wrist and metacarpophalangeal joint involvement, and power Doppler involvement of metatarsophalangeal joints provided independently predictive data. Global ultrasound counts were inferior to minimal power Doppler counts, which significantly improved area under the curve values from 0.905 to 0.962 combined with the Leiden rule. CONCLUSION: In a longitudinal study, extended ultrasound joint evaluation significantly increased detection of joint involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA.

Dark t1 bone marrow.

Bone marrow contains fat and water. Using magnetic resonance (MR) T1-weighted images, fat appears light gray and water appears dark gray. Black or low signal structures include normal cortical bone, bone islands, hemosiderin deposits, calcification, ossification, metal artifact, gas, and foreign material. Reactivation of bone marrow reduces the signal of fatty marrow. Additional sequences and supplementary imaging with conventional radiographs and computed tomography are often helpful in determining the nature of the low signal lesions. Genetic bone disorders such as melorheostosis and other syndromes may give low signal lesion in a typical and often diagnostic pattern. MRI is an important method of showing the fracture line as a low signal lesion on T1-weighted images and is the preferred imaging method when conventional radiographs are unhelpful and fracture is suspected. Infection will cause edema and later sclerosis and necrosis with a mixed low and high signal pattern. Infarction will cause a mixed pattern depending on the stage of the process, but this includes low signal on T1-weighted images. Ossification and calcification in primary and secondary tumors appear as low signal areas on T1-weighted images. Recognition and understanding of lesions that cause low signal on T1-weighted images is an important tool when interpreting MR images.

The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy.

OBJECTIVE: To determine the diagnostic accuracy of commonly used physical tests for subacromial impingement syndrome, using ultrasound as the reference standard. DESIGN: A cross-sectional study of 59 participants with chronic shoulder pain of more than four months duration with a referral for diagnostic ultrasound scanning were invited to participate in the study. MAIN MEASURES: Thirty-four participants met the inclusion criteria and had an ultrasound scan followed immediately by application of the following tests: Neer's sign, Hawkins and Kennedy test, painful arc of abduction, empty and full can tests, resisted isometric shoulder abduction and resisted isometric shoulder external rotation. Using the two-way contingency table method sensitivity, specificity, likelihood ratios and overall accuracy were calculated for each physical test. RESULTS: Diagnostic values for each test varied considerably. The Hawkins and Kennedy test was the most accurate test for diagnosing any degree of subacromial impingement syndrome (71.0%). The most accurate tests for diagnosing subcategories of impingement were pain on resisted external rotation and weakness during the full can test (63.6%) for presence of subdeltoid fluid, pain on resisted external rotation (58.8%) for partial thickness tears and the painful arc test (62.1%) for full thickness tears. CONCLUSIONS: As the predictive values of these tests are shown to be variable in this study it indicates that the clinical tests identified have limited use in informing diagnosis. Emphasis on the management of dysfunction may be more appropriate rather than reliance on clinical tests with inconclusive sensitivity and specificity if ultrasound scanning is not available.

Magnetic resonance imaging, ultrasound and real-time ultrasound elastography of the thigh muscles in congenital muscle dystrophy.

Congenital muscle dystrophy includes a range of genetic disorders characterized by muscle weakness and contractures. We report the magnetic resonance (MR), ultrasound (US) and real-time sonoelastography (RTE) imaging findings of the thigh muscles of a 15-year-old boy with Bethlem myopathy diagnosed with clinical, electromyographic and histopathological criteria. Ultrasound and MR showed hyperechoic appearance and high signal intensity on T1- and T2-weighted sequences respectively at the periphery of the vastus lateralis and the long head of the biceps femoris muscles, and at a central area within the rectus femoris muscles. RTE was employed to examine the elastic properties of the muscle. The elastograms were presented as colour-coded maps superimposed on the B-mode images and revealed that the elastographic pattern correlated with the MR and US pattern of involvement. The abnormal muscle areas were stiffer (blue) than the normal-appearing areas (green), a finding that probably correlates with the presence of dystrophic collagen at the affected areas. This report suggests that RTE could be used as an additional imaging tool to evaluate the pattern of muscle changes in congenital myopathy. Further studies are needed to investigate the specificity and clinical value of RTE in the diagnosis and monitoring of neuromuscular disease.

Romantic Relationships from Adolescence to Young Adulthood: Evidence from the National Longitudinal Study of Adolescent Health.

Theories on romantic relationship development posit a progression of involvement and intensity with age, relationship duration, and experience in romantic relationships. Using the National Longitudinal Study of Adolescent Health, this study tests these propositions by considering relationship type and patterns of relationships over the course of adolescence and their influence on relationship formation in young adulthood. Findings indicate that relationships become more exclusive, dyadic, of longer duration, and more emotionally and sexually intimate over the course of adolescence. Moreover, relationship experience in adolescence is associated with an increased likelihood of cohabitation and marriage in young adulthood. These findings indicate that instead of being trivial or fleeting, adolescent romantic relationships are an integral part of the social scaffolding on which young adult romantic relationships rest.

Radiographic/MR Imaging Correlation of the Elbow.

This article covers the use of radiographs and MR imaging for diagnosing elbow disorders. It concentrates on these techniques, but other imaging techniques including computed tomography, ultrasound, and nuclear medicine are discussed when clinically important. The article covers the use of imaging for specific symptoms including lateral, medial, anterior, posterior and generalized elbow pain, focal swelling, restriction of movement, locking, and neurologic symptoms. Radiographs have been the mainstay of initial imaging of the elbow, while ultrasound examination is often used for soft tissue disease. MR imaging has the advantage over radiographs and ultrasound in accurately examining bone and soft tissue together.

Image guided injection therapies in athletes-Do they work and what should we be using?

In the modern management of the injured elite athlete, the goals of guided injection therapies have extended beyond simple reduction of pain to enhancement of tissue healing and accelerated return to competition, faster than natural healing can allow. This article will review the injection therapies which are frequently used in elite sports injury management and describe other less commonly used injection therapies that are available to the treating clinician and athlete. The evidence base, where available, for each treatment option will be summarised.

Shoulder ultrasound imaging-integrating anatomy, biomechanics and disease processes.

This article brings together the anatomy, biomechanics and the imaging of shoulder disease using ultrasound to enable a better understanding of the strengths and weaknesses of ultrasound when imaging the shoulder.

High-resolution ultrasound in the diagnosis of upper limb disorders: a tertiary referral centre experience.

The purpose of this study is to determine the reliability of high-resolution ultrasound (HRUS) in the diagnosis of upper limb disorders compared with the initial clinical opinion. We prospectively studied 178 patients referred for HRUS examination (47.2% hand, 34.8% wrist, and 18% elbow examinations) by recording the clinical opinion, the specific ultrasound diagnosis, and the final diagnosis, as established by surgery (79.9%) or follow-up (20.1%). HRUS examination was highly reliable in diagnosing cystic lesions, synovial disease, ligament injury and foreign bodies (100%), and slightly less reliable for solid lesions (82.1%) and nerve, bone, and tendon disorders (97%, 91.7%, 86.5%, respectively). HRUS examination resulted in significantly more correct diagnoses (92.1%) than the clinical opinion (70.8%) (McNemar test, P = 0.001). The agreement between the HRUS diagnosis and the clinical opinion was slight (Kappa test, k = 0.16). HRUS examination is more reliable than clinical examination in diagnosing upper limb disorders.

The diagnosis and management of shoulder pain.

Diagnosis is crucial in decision-making when treating a patient with shoulder pain. Ultrasound is also very important in the diagnostic and therapeutic pathway, especially when surgery is being considered. This article outlines the diagnostic pathway using the patient's history, physical examination and ultrasound examination. It is important to correlate the clinical assessment with the imaging signs. It is also important to treat the patient and not the images as there may be abnormalities detected on imaging that are not symptomatic. The article covers the important diagnosis of subdeltoid subacromial bursitis, glenohumeral joint capsulitis, calcific tendinosis, acromioclavicular joint osteoarthritis and long head of biceps tendinosis. It will guide the reader in how to use the findings to treat, using ultrasound-guided injection and other techniques, including steroid injections, hydrodilatation, barbotage and extracorporeal shockwave treatment. These are discussed with the knowledge from over 30 years of experience with a literature review evidential support. I have included tips to make these procedures more effective in treatment and final outcome. There is discussion regarding the use of steroid injections in the presence of a rotator cuff tear and how to proceed if the patient has more than one disease process. The sensible use of steroids and local anesthetics are included, bearing in mind that lidocaine and high concentrations of long-acting local anesthetics are chondrotoxic and should not be injected into joints.

The use of ultrasound in athletes.

Ultrasound is being used by sports physicians in their daily practice to problem solve, but there is still a reluctance for some radiologists to embrace this technique. It has become the "stethoscope" of the sports physician as it is freely available to have in the office setting (Tok, et al. [1]). This has been made possible by advances in technology making it cheaper and more affordable. In the United Kingdom, ultrasound has been performed by sports physicians, rheumatologists, surgeons, physiotherapists, podiatrists, anaesthetists, neurologists and emergency care physicians. It has become a core area of the curriculum in some of these specialties. In athletes it not only provides confirmation of the diagnosis but leads to a better treatment algorithm and can be used to direct intervention. Radiologists need to be aware of its strengths and weaknesses even if they are not able to perform such examinations.

Ultrasound in sports medicine--a critical evaluation.

This article will discuss the aspects of sports medicine where ultrasound imaging has advantages when compared to MRI looking at the strengths and weaknesses of ultrasound in the context of diagnosis and management. It will also assess the use of ultrasound in therapy including guided injections and current thoughts on novel forms of treatment. We will particularly emphasise the role of ultrasound imaging in the management of injuries of tendon, ligament and muscle.

Ultrasound-guided intervention in the ankle and foot.

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

Increased occurrence of pesticide residues on crops grown in protected environments compared to crops grown in open field conditions.

Crops grown under plastic-clad structures or in greenhouses may be prone to an increased frequency of pesticide residue detections and higher concentrations of pesticides relative to equivalent crops grown in the open field. To test this we examined pesticide data for crops selected from the quarterly reports (2004-2009) of the UK's Pesticide Residue Committee. Five comparison crop pairs were identified whereby one crop of each pair was assumed to have been grown primarily under some form of physical protection ('protected') and the other grown primarily in open field conditions ('open'). For each pair, the number of detectable pesticide residues and the proportion of crop samples containing pesticides were statistically compared (n=100 s samples for each crop). The mean concentrations of selected photolabile pesticides were also compared. For the crop pairings of cabbage ('open') vs. lettuce ('protected') and 'berries' ('open') vs. strawberries ('protected') there was a significantly higher number of pesticides and proportion of samples with multiple residues for the protected crops. Statistically higher concentrations of pesticides, including cypermethrin, cyprodinil, fenhexamid, boscalid and iprodione were also found in the protected crops compared to the open crops. The evidence here demonstrates that, in general, the protected crops possess a higher number of detectable pesticides compared to analogous crops grown in the open. This may be due to different pesticide-use regimes, but also due to slower rates of pesticide removal in protected systems. The findings of this study raise implications for pesticide management in protected-crop systems.

Post-traumatic false aneurysm in a digital artery of the finger.

Despite the high incidence of trauma involving the hand and digits, traumatic aneurysms in this region are rarely seen and few are reported. We describe a false aneurysm of a digital artery caused by a dog bite.

Traumatic correction of Linburg-Comstock anomaly: a case report.

Linburg-Comstock anomaly describes an anatomical variant of flexor tendons of the hand. Flexor pollicis longus (FPL) sends a connecting tendon to flexor digitorum profundus (FDP), causing simultaneous flexion at the distal interphalangeal joint (DIPJ) of the index finger when the interphalangeal joint (IPJ) of the thumb is flexed. Epidemiological studies have revealed a unilateral prevalence as high as 31% of individuals; however, the condition rarely causes symptoms. The anomaly can present with a restrictive flexor tenosynovitis, requiring explorative surgery to confirm the diagnosis and disconnection of the anomalous tendon slip to relieve symptoms. We describe the case of a rock climber who suffered a forced extension injury to the DIPJ of the right index finger, resulting in traumatic rupture of his anomalous FPL-FDP connecting tendon. This is the first reported case of rupture of a Linburg-Comstock anomaly. Through rupture of this anomalous tendon, the patient can be viewed as having corrected his aberrant tendon to conform with the more prevalent anatomical configuration and function. We identified the rupture using dynamic ultrasound of the wrist; to our knowledge, this technique has not been described previously in the literature. We recommend the use of this imaging modality to confirm diagnosis, thus avoiding explorative surgery.