Pediatric Musculoskeletal Ultrasonography

373 Pages·2020·30.389 MB·English

by  Yasser El Miedany

Matthew P. Lungren
Michael R.B. Evans
Editors
Pediatric
Clinical Medicine
Musculoskeletal
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Ultrasonography
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Second Edition
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Pediatric Musculoskeletal
Ultrasonography
Yasser El Miedany
Editor
Pediatric
Musculoskeletal
Ultrasonography
Editor
Yasser El Miedany
Medway Foundation Trust
King’s College London
London
UK
ISBN 978-3-030-17823-9 ISBN 978-3-030-17824-6 (eBook)
https://doi.org/10.1007/978-3-030-17824-6
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Wherever the art of medicine is loved, there is also a love of
humanity.
Hippocrates
Everyone has a soulmate who supports, encourages, and
motivates them to achieve their ambitions in life. This book is
dedicated to mine as well as all the special people in
everyone’s life.
Preface
The use of musculoskeletal ultrasonography in rheumatology clinical prac-
tice has expanded swiftly over the past decade as an outcome of the techno-
logical developments and implementation of the window of opportunity
concept in most of the inflammatory musculoskeletal conditions. Ultrasound
booked its place as the “rheumatologist’s stethoscope” as it enabled the treat-
ing health-care professional to diagnose, prognosticate, and monitor disease
activity as well as response to management. In contrast to other imaging
modalities such as X-ray and magnetic resonance, ultrasound has clear
advantages, namely, good tolerability, no radioactivity, ability to scan both
joints and soft tissue at one sitting, and its dynamic facility, which enables
direct correlation between clinical and imaging outcomes. In spite of some
concerns regarding standardization, the use of ultrasound in rheumatology is
expected to grow further as prices of the machine fall and the opportunity to
practice improves.
In contrast with musculoskeletal ultrasonography in adults which has been
thoroughly studied and become a well-established tool for patients’ assess-
ment both in research and clinical practice, musculoskeletal ultrasonography
use in pediatrics is still limited. This is surprising, given the great potential
and advantages of this technology for the assessment of the musculoskeletal
system in children. Ultrasound is well-tolerated by children; therefore, it can
be considered a typical first-line modality for a wide array of pediatric mus-
culoskeletal imaging indications. Being readily accessible in both emergency
and outpatient settings, ultrasound allows the health-care physician/sonogra-
pher to perform a dynamic assessment of the musculoskeletal system without
using ionizing radiation or sedation. Unlike MRI, which requires the clinician
to select a focal area of concern, ultrasound enables the evaluation of multiple
joints or lesions in a single session and permits the operating person to rap-
idly compare abnormal structures to the contralateral side. Panoramic images
also allow an expanded view and can be useful when assessing larger lesions.
In addition, musculoskeletal ultrasonography started to book its place in
patients’ monitoring as it facilitates the ability to detect subclinical synovitis
in children with JIA.
There are significant differences between joints of adults and children due
to the age-related peculiarities of bone and joints in the immature skeleton,
such as the presence of non-ossified cartilage and of a physiologically
enhanced Doppler flow attributed to nutrient vessels. Therefore, this book
was formatted to cover a whole range of musculoskeletal ultrasonography in
ix
x Preface
pediatrics. In the first section, the fundamentals of pediatric musculoskeletal
ultrasonography are discussed. Two chapters have been dedicated to sono-
anatomy and differences between adults and children. Each approach to the
relevant pediatric sonoanatomy is accompanied by clinical pearls to aid read-
ers acquire as well as interpret ultrasound images of the area of interest with
ease, provide guidance for successful intervention, and avoid pitfalls. This is
followed by the second section which covers a whole range of anatomical
sites, shoulder and arm, elbow and forearm, wrists and hands, hip and thigh,
knee and leg, as well as ankle and feet. Scans for normal sonoanatomy as well
as possible pathology are included. The third section discusses the use of
ultrasonography in juvenile inflammatory arthritic conditions such as inflam-
matory arthritis and spondyloarthritis. In response to several of our col-
leagues’ requests, we dedicated a specific section for musculoskeletal
ultrasonography in standard practice, reporting US scans and US-guided
interventional procedures in pediatrics. Section 5 discusses the use of US in
children with sports injuries, whereas the last section summarizes advances in
pediatric musculoskeletal ultrasonography.
The main theme of this book was to deliver a very practical and reader-
friendly guide. On one hand, it describes a “how-to-do-it” approach, while, in
the meantime, it delivers the evidence and advanced knowledge base of the
relevant pathological sonographic appearances of the various musculoskele-
tal tissues. The illustrations and figures were meticulously selected to give the
reader a clear guide toward implementation in real-life practice. Focusing on
the major values of ultrasound in pediatric musculoskeletal conditions, this
book with its 20 chapters is expected to fill an important void in the current
literature. It represents what can be considered to be the best current thinking
on the role of ultrasonography in the assessment of pathology, diagnosis, and
treatment of different musculoskeletal pediatric diseases. Therefore, this
work can serve as both excellent introductory and a very good reference
resource for future reading.
This book has been the outcome of cooperative effort of a large interna-
tional group of leaders in musculoskeletal ultrasonography. They have done a
superb job in producing authoritative chapters including vast amounts of sci-
entific and clinical data to create state-of-the-art descriptions of sonographic
changes encompassed by different rheumatic diseases. Special thanks to
Professor Angelo Ravelli who wrote the book’s foreword and to everyone
who helped me bring this book to light.
Personally, I feel privileged to have compiled this work and am enthusias-
tic about all that it offers to our readers. I hope you too will find this edition a
uniquely valuable educational resource.
London, UK Yasser El Miedany
Foreword: A Beautiful and Well-Deserved
Textbook of Pediatric Musculoskeletal
Ultrasonography
In the past two decades, there has been important progress in the manage-
ment of juvenile idiopathic arthritis, which includes the shift toward early
aggressive interventions, the availability of newer and potent therapeutic
agents, and the development of innovative treatment strategies. These
advances have increased considerably the potential to achieve disease
remission or, at least, minimal levels of disease activity and have conse-
quently moved the therapeutic aims increasingly toward the attainment of
an inactive disease status. In addition, they have made it important to iden-
tify patients with a high likelihood of developing erosive joint damage pre-
cociously, so as to institute appropriately aggressive therapy at an early
stage of the disease. These issues have raised the need for sensitive methods
that enable a precise definition and monitoring of the synovial inflammation
process. Of the diagnostic tools currently available, ultrasonography is best
suited for these purposes.
Ultrasonography has several advantages over other imaging modalities,
including noninvasiveness, rapidity of performance, relatively low cost, abil-
ity to scan multiple joints in the same session, comparison between symp-
tomatic and asymptomatic sites, dynamic study, repeatability, and high
acceptability among children and parents. In addition, it does not involve
exposure to ionizing radiations, does not require sedation, and is the only
imaging technique that can be coupled with the conventional approach to
patient assessment in the clinic. Recent studies in children with juvenile idio-
pathic arthritis have shown that ultrasonography may be more accurate than
clinical evaluation for demonstrating joint inflammation and enthesitis, has
the ability to detect subclinical synovitis, may improve patient categorization
into the current classification schemes, and could alter the selection of patients
who are candidates to receive synthetic or biologic disease-modifying anti-
rheumatic drugs. Moreover, it was found to possess the potential to measure
the integrity of articular cartilage and to capture early bone erosions. Owing
to its capacity to precisely locate inflamed areas, ultrasonography can provide
a guidance to corticosteroid injections into the joints, tendon sheaths, or other
periarticular structures.
There are, however, several challenges with the use of ultrasonography. It
is the most operator-dependent imaging technique, its validity is highly
related to the properties of the machine used, and it has a limited value for
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xii Foreword: A Beautiful and Well-Deserved Textbook of Pediatric Musculoskeletal Ultrasonography
the assessment of some musculoskeletal areas, such as the axial skeleton.
Furthermore, it requires continuous practice after appropriate training.
Specific problems encountered with its application in children are related to
the unique features of the growing skeleton, which include age-related varia-
tions in the thickness of the articular cartilage and incomplete ossification. A
thorough knowledge of the sonoanatomy changes at the different growth
ages is, therefore, essential to distinguish physiological appearance from
pathological findings. To overcome this shortcoming, the availability of nor-
mative data regarding the influence of different ages, stages of growth, and
puberty is critical. In younger children with chronic arthritis, the difficulties
are compounded by the development of distinctive abnormalities, such as
disturbance of bone growth and maturation. It has also been argued that to
consider any Doppler signal as a sign of synovitis might be problematic
owing to physiologically enhanced blood flow. A number of initiatives aimed
at improving the reliability and standardization of ultrasonography assess-
ment in the pediatric age group are ongoing under the umbrella of the
EULAR and the OMERACT.
In recent years, the clinical and research interest in musculoskeletal
ultrasonography in children has grown sharply. There is, therefore, an
urgent need of educational initiatives and teaching materials that help the
practitioners who wish to apply this imaging modality to gain the necessary
background and skills. This textbook edited by Yasser El Miedany meets
fully these requirements and represents a major achievement in the field. It
includes a series of chapters written by the leading international experts in
pediatric musculoskeletal ultrasonography, which address all aspects
related to the use of this technique in children and adolescents and provide
the readers with all theoretical and practical information necessary to per-
form an appropriate assessment of their patients. The first section illustrates
the fundamentals of musculoskeletal ultrasonography, from the most
detailed technical aspects to the comparison of sonoanatomy between chil-
dren and adults, to the spectrum of tissue pathology and clinical applica-
tion. In the second section, the authors present a thorough description of the
ultrasonographic findings in individual anatomic sites, including joints,
vertebral spine of infants and neonates, and nerves. The features seen in
inflamed joints and periarticular structures in patients with juvenile idio-
pathic arthritis and spondyloarthropathies are described in the third section.
The last three sections are dedicated to the application of ultrasonography
in standard clinical practice and in sport medicine and to an update on the
recent advances in this area of imaging. All chapters are enriched with a
vast and accurate iconography, which make more enjoyable the readings
and offer valuable examples and references for comparison with ultrasono-
graphic assessments actually performed in the clinics. In conclusion, I wish
to congratulate Yasser El Miedany for accomplishing such an important,
timely, and prestigious editorial engagement. I’m sure that this textbook
will encounter a great success and will become a fundamental manual for