Ultrasound From Elbow to Finger Tip. Dr Mark Roger Consultant Radiologist

Transcription

1 Ultrasound From Elbow to Finger Tip Dr Mark Roger Consultant Radiologist

2 Fast Cheap Dynamic real >me Painless Radia>on free No tunnels Direct pa>ent interac>on/history/examina>on Two sides for comparison

3 Appendicular Skeleton Superficial joints and soh >ssues easy to examine High image resolu>on Variety of high resolu>on transducers Allows accurate targe>ng for treatment procedures

4 U>lity of Ultrasound DIAGNOSTIC TREATMENT

5 Diagnos>c

6 Presenta>on Lump/swelling Pain Arthropathy Tendon/ligament Muscle Dysfunc>on Structural Neural Idiopathic Sports Overuse Trauma

7 Ganglion / synovial cyst Synovi>s Bursi>s Thrombophlebi>s Lymph node Vascular malforma>on Tumours Lipoma Palmar fibroma Nerve sheath Non- specific LUMPS

8 Ganglion/Synovial Cyst

9 Synovi>s

10 Bursi>s

11 Thrombophlebi>s Epitroclear Node

12 Lipoma

13 Palmar fibroma/dupytren s

14 Nerve Sheath Tumour

15 Malignancy

16 Solid masses OHen non- specific Require referral and MRI

17 The Use of Ultrasound in the Evalua>on of SoH Tissue Tumours - Revisited H Kwok, C Pinto, A Doyle New Zealand Bone and SoH Tumour Registry Middlemore Hospital Auckland, New Zealand

18 Report Recommenda>on vs Pathology Suspicious diagnosis or further evaluation suggested Benign diagnosis and no further recommendation Subtotal Pathology Non-benign Benign False nega>ve rate = 15% (95% CI = 6-24%) No sta>s>cal difference compared to study from the preceding 10 years

19 Arthropathy Joint swelling Effusion Synovi>s Dysfuc>on Synovi>s Bone erosion Tendon swelling / pain / s>ffness Tenosynovi>s Bursi>s

20 Carpal Synovi>s

21 Elbow RA

22 MCP RA

23 Tenosynovi>s

24 Sports / Overuse / Trauma Epicondyli>s Bursi>s Tenosynovi>s Muscle / tendon tear Nerve injury Foreign body

25 Epicondyli>s

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27 Distal Biceps

28 Tendon Rupture

29 Extensor Hood Tear

30 Triceps Avulsion

31 Gamekeeper s Thumb

32 Finger Pulleys

33 Trigger Finger

34 Glass and Wood

35 Nerve Damage Tunnel syndromes Impingement syndromes Nerve tumours Muscle atrophy from denerva>on

36 Ulnar Nerve

37 20% Asymptoma>c Snapping Ulnar Nerve

38 Carpal Tunnel

39 Treatment

40 Ultrasound Guided Treatment Aspira>on Steroid / Local anaesthe>c injec>on Dry needling Autologous blood injec>on Platelet rich plasma injec>on Prolotherapy

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42 Aspira>on Infec>on? Crystals? Bursi>s Ganglion 40-60% resolve spontaneously Aspira>on ohen followed by steroid injec>on Reported very low recurrence rate aher single treatment.

43 Steroid/Local Anaesthe>c Bursi>s Synovi>s Tenosynovi>s Epicondyli>s Short term pain relief Reported improvement at 6 weeks but not at 1 year (vs Physio, NSAIDS) Smidt et al. Pain 2002;96: Weak evidence in the literature. Overall steroids not of proven benefit

44 Epicondyli>s Op>ons AHer failed conserva>ve management Physiotherapy NSAIDS Bracing/strapping Shock therapy Low level laser therapy Dry needling / Autologous Blood Dry needling / Platelet rich plasma Prolotherapy/Polidoconol Stem cell / Autologous Tenocyte Injec>on Surgery

45 Dry Needling with Autologous Blood Injec>on Dry needling fenestrates the tendon crea>ng clehs. Blood injected into tendon entering clehs Blood contains growth factors to induce fibroblast prolifera>on and collagen forma>on Second treatment recommended at 4-6 weeks

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51 Kazemi and colleagues (2010) and Jindal et al (2013) compared local cor>costeroid with autologous blood injec>ons Both concluded that autologous blood was more effec>ve in short- term (8 and 6 weeks respec>vely) than cor>costeroid injec>on Jindal et al. Journal of Orthopaedic Surgery and Research 2013, 8:10 Kazemi et al. Am J Phys Med Rehabil. 2010;89(8):

52 Platelet Rich Plasma Platelets contains storage pools of growth factors to promote fibroblast prolifera>on PRP is a concentrated dose of platelets and therefore growth factors 3-8 >mes that of whole blood

53 Mishra and Pavelko (2006). 140 pts. At final follow- up (mean of 25.6 months; range of 12 to 38 months), the PRP- treated pa>ents reported a 93 % reduc>on in pain compared with before the treatment (p < ). Peerbooms and associates (2010). 100 pts. Treatment of pa>ents with chronic lateral epicondyli>s with PRP reduces pain and significantly increases func>on, exceeding the effect of cor>costeroid injec>on. Mishra, Pavelko. Am J Sports Med. 2006;34(11): Peerbooms et al. Am J Sports Med. 2010;38(2):

54 Mishra et al Randomised, double- Blind, Prospec>ve, Mul>center controlled Trial of 230 Pa>ents. Followed for 24 weeks. Dry needling (ac>ve control) vs PRP and Dry needling Greater propor>on had improved pain and tenderness scores at 24 weeks in PRP group Platelet- Rich Plasma Significantly Improves Clinical Outcomes in Pa>ents With Chronic Tennis Elbow Mishra et al. Am J Sports Med July 3, 2013 ; published online before print July 3, 2013,

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56 Prolotherapy Injec>on of irritant/sclerosant to insight an inflammatory response and fibroblast prolifera>on Hyperosmolar dextrose

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58 Summary - Ultrasound superb diagnos>c tool for upper limb assessment - Excellent first line imaging inves>ga>on in many serngs - Can target treatment op>ons in certain clinical serngs

59 A Breath of Fresh Air..

60 Occult Wrist Fractures

61 The occult # or stress # Now Nega>ve trauma Xray Immobilise Repeat Xray Consider further immobilisa>on Unresolved Specialist MR..CT..Bone scan Maybe Nega>ve trauma Xray Mri fast scan Or CT fast scan Defini>ve Rx Accurate prognosis

62 MRI: Imaging Nega>ve?wrist # MRI: Brydie, Bri-sh Journal of Radiology, pts snu@ox tenderness, neg films All had MRI w/in 2 wks (most w/in 3d) 37 (19%) had scaphoid fx 37 (19%) had another fx detected Recommend early MRI, forget splint if Nega-ve

63 Consider a fast MRI protocol Referral base and price? What about Ankle and Pelvis?

64 Thank you