CRUS-SURC - The Foot and Ankle sonoanatomy, …...PowerPoint Presentation Author Roth, Johannes...
Transcript of CRUS-SURC - The Foot and Ankle sonoanatomy, …...PowerPoint Presentation Author Roth, Johannes...
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Johannes Roth, MD PhD FRCPC RhMSUS
The Foot and Ankle –
sonoanatomy, relevant pathology & needle approach
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Nothing to disclose
Illustrations have been adapted from C Martinoli
Thank you to the sponsors of this courseAbbvie, BMS, and Johnson& Johnson
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Objectives
• Review the sonoanatomy of the foot and ankle
• Discuss relevant pathology
• Describe ultrasound guided interventions
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Planning of Joint InjectionAnkle second most frequently affected joint in JIA (knee most common)
RR of Relapse following ankle injection double compared to knee (Zulian 2003)
Rooney et al, J Rheumatol 2009, “Ultrasound findings in clinically swollen ankles”
34 JIA Patients with swollen ankles
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Sonoanatomy
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Talus
Capsule
Tibiotalar long
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Anterior (Tibiotalar) transverse
Talus with cartilage on top
Tib ant Ext Hall. Ext Dig.
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Hoffa
Perimalleolarmedial transverse
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Lateral Ankle
PL PBMalleolus Peroneus
tendons
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Subtalar Joint
A = Anterior Facet
B= Medial Facet
A+B = Anterior Subtalar Joint
C = Posterior Facet = PSTJ
D = Sinus Canal
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Talus Navic.
Talonavicular
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Tib post Flex Dig
Talus Sustentaculum Flex hall
Subtalar Joint medial
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Sinus Tarsi Slide –Subtalar Joint from lateral
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Tib Talus Calcaneus
Posterior Subtalar (and Tibiotalar)
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PlantarFascia
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Midfoot longitudinal scan
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Dorsal Longitudinal & Transverse Scan
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IP
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Pathology
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Pathology Anterior
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Injection avoid the artery
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Talonavicular
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Talonavicular
Move across !
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Talonavicular – move the joint !
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?
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Synovitis Subtalar medial (ASTJ)
Talus Calcaneus
** = Effusion
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Synovitis Subtalar lateral (PSTJ)
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Tenosynovitis Peroneal
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Plantar Fasciitis
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Bursitis
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Synovitis IP joint
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Patient 1:13 year old, JIA, national cheerleading champion
• Treated with DMARD
• Presenting with recurrence of right ankle pain
• On exam mild swelling, mild restriction in range of motionof tibiotalar and subtalar joint, pain on medial aspect ankle
• ? Overuse with training, ? flare of JIA
• ? Joint injection, ? Change of systemic medication
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A thirteen year old with JIA and ankle pain
Tib post
Sustentaculum talli
Tib post
TalusTibia Talus
Sinus tarsi talonavicular
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Injection
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13 year old national cheerleading champion
• Targeted injection tibialis post tendon sheath
• Lateral subtalar joint
• Outcome complete remission for now 2 years
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Patient 2:
• 4 year old girl presenting with likely longstanding JIA, polyarticular
• Leg length discrepancies• Growth delay• Excellent response to MTX, full resolution of
polyarthritis but persistent morning stiffness, limp, points to her knees
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Visualization of synovitis (movement)
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Injection
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Injection
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Injection
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Posterior Subtalar Joint Sinus Tarsi approachSmith J et al J Ultrasound Med 2015; 34:83–93
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Patient 3:Relapse in a 16 year old poly JIA
Calcaneus Cuboid
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Calcaneocuboid
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Patient 4: a colleague
healthy
pathologic
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• Peritendinous vs intratendinous vs entheseal injection
• Which agent ? Steroid, PRP, Sclerosing Agent, Glucose
• Rupture ? Only in steroids but may be because of lack of training
• (Reversible) sc atrophy•
Duration of effect (Cochrane limited, but might need to be repeated)
Fredberg U Scand J Rheumatol 2004;33:94–101Kearney RS Cochrane Database of Systematic Reviews 2015 Srivastava P, Indian Journal of Rheumatology 9 · November 2014
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Various presentations may require various approaches
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Patient 5: 17 year old with enthesitis related arthritis
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Patient 6: 10 year old with sJIA
Outcome: Complete resolution of findings and symptoms
10 year old sJIA patient coming in for routine Tocilizumab treatment.Noticed area of swelling of midfoot and forefoot, painful.
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Patient 7: Monarthritis of the toe
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Patient 8: Keloid in a 9 year old with EF and LS
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And now try it yourself !!!