Ultrasound in practice

Clinical case studies

How might ultrasound add value to aid diagnosis, assessment of therapeutic response and the assessment of disease state?

Background
  • 30-year-old female
  • Pain in wrists for 6-12 months
  • Early morning stiffness – 10 mins; pain > stiffness
  • Depending on paracetamol; not wanting to use non-steroidal anti-inflammatory (NSAID)
  • Regular gym user; symptoms worse after use
  • Observation and examination
    • Hypermobile; score 5/9
    • Puffiness bilateral ulnocarpal joint; non-tender
  • C-reactive protein (CRP) < 5
  • ESR 10 mm/hour
  • Cyclic citrullinated (CCP) antibody 3.6 U/ml (N < 2.99)
  • X-rays of hands and feet – normal
Ultrasound findings

Scenario 1: Minimal grey scale in wrist
Non-significant inflammation, possibly element of overuse in benign hypermobility. Suggested management: conservative (splint +/- intra-articular injection, exercise advice)

Scenario 2: Grade 2 grey scale and grade 2 power Doppler (PD) in both ulnar carpal joints + mild erosive change of the ulna styloids bilaterally?
Evolving inflammatory arthritis – ­ risk of persistent erosive arthritis – grade 2 PD and erosions. Suggested management: conventional sDMARD (csDMARD) +/- intra-articular injection

How did ultrasound add value?

Changed diagnosis and management

Case study 1

Diagnosis

Case study 2

Therapeutic Response

Case study 3

Remission

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