Ultrasound Features of the Normal and Pathologic Periosteum

Serial Ultrasonography for the Assessment of Healing of Lower Extremity Bone Stress Injury and Correlation With Return to Sport/Exercise

BACKGROUND

Lower extremity bone stress injuries (BSIs) are common among athletes who participate in high-impact activities. Conventional imaging is limited in assessing healing of BSIs.

HYPOTHESIS

Serial ultrasonography (US) can identify changes in appearance of lower extremity BSIs over time that can be correlated with symptoms and return to exercise/sport.

STUDY DESIGN

Cohort observational study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Adults 18 to 50 years old with a recent exercise-associated BSI of distal tibia/fibula or metatarsals diagnosed by magnetic resonance imaging (MRI) were enrolled. US was performed every 2 weeks for 12 weeks. The sonographic appearance (soft tissue edema, periosteal reaction, hyperemia on power Doppler, callus) was correlated with the numerical rating scale (NRS) for pain and ability to return to sport/exercise.

RESULTS

A total of 30 patients were enrolled (mean age, 35.3 ± 7.7 years; 21 [70.0%] female). The tibia was most frequently affected (n = 15, 50.0%), followed by metatarsals (n = 14, 46.7%) and fibula (n = 1, 3.3%). At week 4, 25 of 30 (83.3%) had at least 1 US finding associated with the BSI. The degree of hyperemia was correlated with NRS at weeks 4 and 6 (Spearman correlations [ρ] 0.45 [0.09, 0.69] and 0.42 [0.07, 0.67], respectively), as well as return to sport/exercise at week 6 (ρ -0.45 [-0.68, -0.09]). US soft tissue edema was also correlated with NRS at week 6 (ρ 0.38 [0.02, 0.65]).

CONCLUSION

Serial US of lower extremity BSIs can provide objective measures of healing. US findings were correlated with clinical outcomes at multiple timepoints.

CLINICAL RELEVANCE

US may have advantages over conventional imaging for monitoring healing of lower extremity BSIs. Further research is needed to better understand the prognostic value of these sonographic indicators of BSI healing and role in assessing readiness for return to sport/exercise.

Ankle retinacula abnormalities as features of psoriatic arthritis: An ultrasound study

OBJECTIVE

To compare the ultrasonography (US) assessment of the retinacula of ankles in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

METHODS

This cross-sectional study included RA or PsA patients with ankle pain and healthy controls. The following US features were recorded: presence of synovitis, tenosynovitis and abnormalities of two retinacula (the superior peroneal retinaculum [SPR] and the flexor retinaculum [FR] evaluated in mode B and power Doppler).

RESULTS

Among the 80 included patients, 37 (46%) and 23 (29%) had RA and PsA; 20 (25%) patients were healthy controls. The FR was thicker in PsA than RA ankles 0.96±0.39 vs. 0.64±0.15, P<0.001 with no difference between RA patients and HCs. Other FR abnormalities such as hypoechogenicity, PD positivity or periostosis were more frequent in PsA than RA patients, P<0.001. On receiver-operating-characteristic curve analysis, a cut-off of 1mm FR thickness provided a sensitivity of 49% and specificity of 97% for the diagnosis of PsA. Overall, 39 and 3% of PsA and RA ankles exhibited retinaculitis of FR (thickness≥1mm with hypervascularization or hypoechogenicity). The two disease groups did not differ in the evaluation of SPR.

CONCLUSIONS

US abnormalities of FR were more frequent in PsA than RA and appeared to be specific for PsA. US assessment of FR might be useful to distinguish RA and PsA.

High-resolution ultrasound in the evaluation of musculoskeletal infections

Soft tissue and osseous musculoskeletal infections are common but can be difficult to diagnose clinically. Signs, symptoms, and physical examination findings may be nonspecific, and laboratory values can be inconclusive. The extent of disease may also be underestimated on physical examination. Soft tissue infections most commonly occur secondary to direct inoculation from broken skin and less frequently due to the seeding of the soft tissues from hematogenous spread, while osseous infections are more commonly due to hematogenous seeding. Infections may also be iatrogenic, following surgery or other procedural interventions. High-resolution ultrasound is an extremely useful imaging modality in the evaluation of musculoskeletal soft tissue and joint infections, and can occasionally be used to evaluate osseous infections as well. Ultrasound can aid in the early diagnosis of musculoskeletal infections, allowing for prompt treatment, decreased risk of complications, and treatment optimization. Ultrasound is sensitive and specific in evaluating soft tissue edema and hyperemia; soft tissue abscesses; joint, bursal and tendon sheath effusions/synovitis; and subperiosteal abscesses. This article describes the typical high-resolution grayscale as well as color and power Doppler ultrasound imaging findings of soft tissue infections including cellulitis, fasciitis, necrotizing deep soft tissue infection, pyomyositis, soft tissue abscess, infectious bursitis, and infectious tenosynovitis. Ultrasound findings of septic arthritis as well as osteomyelitis, such as subperiosteal spread of infection (subperiosteal abscess). are also reviewed. In addition, the use of ultrasound to guide fluid and tissue sampling is discussed.

Ultrasound imaging of bone fractures

Ultrasound imaging is widely used to evaluate the neuromusculoskeletal system, and recently, a particular interest is mounting in assessing the bone tissue and fractures. Ultrasound can be considered a valuable diagnostic tool to perform a first-line evaluation of bone tissue, especially in particular settings without direct access to X-ray imaging and/or in emergency conditions. Moreover, different healing phases of bone fractures can be accurately assessed by combining the B-mode modality and (high-sensitive) color/power Doppler optimizing the management of patients-e.g., planning of progressive loads and rehabilitation procedures. In this review, we summarized the role of ultrasound imaging in the management of bone fractures and described the most common sonographic signs encountered in the daily practice by assessing different types of bone fractures and the progressive phases of the healing process.

Lower Leg Muscle Stiffness on Two-Dimensional Shear Wave Elastography in Subjects With Medial Tibial Stress Syndrome

OBJECTIVES

We aimed to explore, which muscle stiffness changes may be related to medial tibial stress syndrome (MTSS) and the correlation between the medial tibial periosteal thickness and lower leg muscle stiffness.

METHODS

This study included 63 subjects distributed into 3 groups: the symptomless group, the MTSS group, and the control group. The lower leg muscle stiffness of the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus longus (PL), soleus (SOL), lateral gastrocnemius (LG), medial gastrocnemius (MG), tibialis posterior (TP), and flexor digitorum longus (FDL) in the 3 groups was obtained by two-dimensional shear wave elastography. Differences in the muscle stiffness and medial tibial periosteal thickness in the 3 groups were determined by one-way analysis of variance (ANOVA) and least significant difference tests. The relationships between the periosteal thickness and the muscle stiffness were assessed using Pearson correlations.

RESULTS

The shear wave velocity (SWV) of all lower leg muscles except the EDL was higher in the symptomless and MTSS groups than in the control group (TA, P = .001; PL, P = .006; SOL, P < .001; LG, P < .001; MG, P < .001; TP, P < .001; FDL, P = .013; and ANOVA). A significant difference was found in the SWV of the SOL, TP, and FDL between the control and symptomless groups (P = .041, P < .001, and P = .013, respectively). Moreover, the medial tibial periosteum was thickened after running training, and its thickness was positively correlated with muscle stiffness.

CONCLUSION

The medial tibia periosteal thickness is positively correlated with the lower leg muscles stiffness. Changes in SOL, TP, and FDL stiffness may be related to the occurrence of MTSS.

Ultrasonography of the bone surface in children: normal and pathological findings in the bone cortex and periosteum

Ultrasound (US) is widely used in pediatric musculoskeletal pathology at all ages. Although the focus is often on soft tissues, joints and cartilage, the examiner might be confronted with changes in the underlying bone surface that are important to understand and integrate in the diagnosis. This article illustrates the normal US aspects of the cortical bone surface and periosteum, as well as the most common US anomalies seen in infections, trauma and bone tumors in children.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Bone stress injuries and fatigue fractures of the pelvis in endurance horses

BACKGROUND

Bone stress injuries and fatigue fractures of the pelvis are reported in only a small number of endurance horses.

OBJECTIVES

To describe bone stress injuries and fatigue fracture of the pelvis in endurance horses trained and competing on the deep sand surfaces.

STUDY DESIGN

Retrospective case series.

METHODS

Medical records of horses used for endurance and diagnosed with bone stress injuries and/or fatigue fractures of the pelvis by ultrasound were reviewed. The bone stress injuries and fatigue fractures were classified as affecting the iliac wing, the iliac shaft, the tuber ischiadicum, the rest of the ischium or the pubis and subdivided into four fracture configurations: isolated iliac fracture, isolated fracture of the floor of the pelvis, isolated tuber ischiadicum fracture and multiple fractures. Descriptive statistics were performed overall and on fracture configurations for age, sex, breed, level of activity, affected limbs, previous injuries, development of the injury, seasons in the UAE, physical and dynamic findings and outcome. For each fracture configuration and the outcome, multivariable logistic regression models were developed after univariable logistic regression and collinearity analyses. Significance was set at P ≤ .05.

RESULTS

Sixty endurance horses were included; 48% (95% CI: 36%-61%) had isolated iliac fracture, 17% (7%-26%) isolated fracture of the floor of the pelvis, 15% (6%-24%) isolated tuber ischiadicum fracture and 20% (10%-30%) had multiple fractures. Breed (OR, 4.42; 95%CI, 1.02-19.57) was significantly associated with isolated iliac fracture and asymmetry of bone landmarks (OR, 7.42; 95% CI, 1.47-37.45) with isolated tuber ischiadicum fracture. Degree of lameness (OR, 3.08; 95% CI, 1.07-8.9) and trotting on three tracks (OR, 8.62; 95% CI, 1.43-51.9) were significantly associated with the diagnosis of isolated fracture of the floor of the pelvis.

MAIN LIMITATIONS

Data acquired in a single country.

CONCLUSIONS

Bone stress injuries and fatigue fractures of the pelvis can affect endurance horses trained and competing on deep sand. Isolated bone stress injuries and/or fatigue fractures of the ileum were the commonest followed by multiple pelvic bones involvement. The presence of lameness and trotting on three tracks suggest the presence of bone stress injuries and/or fatigue fractures of the floor of the pelvis; asymmetry of bony landmarks is more commonly detected in horses with bone stress injuries and/or fatigue fractures of the tuber ischiadicum.

Preliminary image findings of lower limb stress fractures to aid ultrasonographic diagnoses: A systematic review and narrative synthesis

INTRODUCTION

This systematic review investigates which image appearances are most common when diagnosing lower limb stress fractures using ultrasound imaging, with the aim of outlining an image critique guideline for operators to support confident diagnoses.

METHOD

A comprehensive literature search of medical databases and handsearching was undertaken to identify relevant studies. All studies were critically examined for quality using the CASP critical appraisal tool. Results from eight studies were combined and interpreted using a narrative synthesis.

FINDINGS

A clear outline of common stress fracture appearances using ultrasound were identified in a combined total of 119 participants. Each finding was ranked according to its popularity. Periosteal thickening (78/119) and cortical disruption/irregularity (83/119) were noted in all eight studies. Hypervascularity of the periosteum visualised by colour Doppler imaging (66/119) was reported in six of the eight studies. Soft tissue hypervascularity (13/119), bony callus formation (5/119) and cortical break (22/119) were seen in three studies.

CONCLUSIONS

Based on the findings, we offer a guideline of the most significant preliminary image findings to be utilised by operators when examining athletes suspected of having lower limb stress fractures. The results show a gap in research for evaluating changes in appearance depending on the injury severity. Further research into distinguishing stress fractures from pathological involvement may in future reduce reliance on plain film radiography.

Ultrasound and bone: a pictorial review

The assessment of bone mainly relies on standard radiographs, CT, MRI, and bone scintigraphy depending on the anatomic region complexity and clinical scenario. Ultrasound (US), due to different acoustic impedance between soft tissues and the bone cortex, only allows the evaluation of the bone surfaces. Nevertheless, US can be useful in the evaluation of several bone disorders affecting the limbs as a result of its tomographic capabilities and high definition. This pictorial review article summarises our clinical experience in adults and reviews the literature on US bone examination. We first present the US appearance of normal bone and the main congenital anatomic variations, after which we illustrate the US findings of a variety of bone disorders. Although US has limits in bone assessment, its analysis must be a part of every musculoskeletal US examination.

Ultrasound features of the subungual glomus tumor and squamous cell carcinomas

BACKGROUND

Nail tumors often pose a significant challenge for the clinician, as they are burdened by a high delay in diagnosis and paucity of clinical signs in the early stage. In most cases, the onset of pain or nail plate dystrophy leads to imaging investigations such as plain radiography, magnetic resonance imaging, and ultrasonography (US) when surgery is pending.

MATERIAL AND METHODS

A 2-year monocentric study evaluated the histologically confirmed cases of subungual glomus tumor (GT) and squamous cell carcinoma (SCC) with a pre-surgical US assessment, and reviewed their sonography features. A total of 7 digital GTs and 6 SCCs of the nail were collected.

RESULTS

GT and SCC are easily distinguishable on US. Compared to SCC, GT was positively associated with an ovoid shape, well-defined borders, bone cup-scalloping without cortical erosion, and a rich intralesional vascular pattern (P < 0.05). Vice versa, SCC was significantly correlated with irregular shape, ill-circumscribed margins, an infiltrative growth pattern with peripheral hypoechoic foci, posterior acoustic shadow, cortical erosion, and a highly vascular multipolar peripheral pattern (P < 0.05).

CONCLUSION

The rapid assessment of GT and SCC sonographic features may contribute to reduce diagnostic delay, expedite management, and decrease the risk of surgical relapse.