EULAR on-line course on Ultrasound

Sonoanatomy
Scanning technique and
basic pathology of the
elbow

Wolfgang A. Schmidt, Sandrine Jousse Joulin, Marina Backhaus

IN-DEPTH DISCUSSION I

Differential diagnosis between rheumatoid arthritis

and gout
 Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

A 75-year old patient was admitted to the hospital with global cardiac insufficiency. In addition, he had swollen
and painful wrists. The MCP 1-3 joints on the right side, the MCP 1, 2 and 5 joints on the left side and the PIP 2
joints of both sides were also swollen. The movement of both ankle joints and both MTP 1 joints was impaired.
Figure 28 shows the patients left hand. CRP and ESR were elevated; rheumatoid factor and anti-CCP
antibodies were negative. The patient had hard nodules on the dorsal side of the forearms below the elbow
that were not displaceable (Figure 29). Uric acid levels were elevated (540 mol/l; 9 mg/dl). Ultrasound of the
nodules revealed hyper-echoic, cloudy structures with partial dorsal shadowing (Figure 30). Ultrasound guided
installation of saline solution allowed aspirating some drops of the installed fluid. Polarization microscopy
revealed intra-cellular sodium urate crystals.

Figure 28. Left hand of the patient with the differential diagnosis of rheumatoid arthritis or gout

2007-2015 EULAR 2
Anatomy images by Sonoanatomy Group - Barcelona University
 Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 29. Left elbow showing a nodule of the forearm distally to the elbow

Figure 30. Ultrasound image of the above mentioned nodule (transverse plane at the forearm)

The rheumatologist needs to differentiate between gout and rheumatoid arthritis as management of both
diseases is considerably different. Ultrasound easily differentiates between rheumatoid nodules and gout
tophi. In fact, the first publication, that has described the sonographic appearance of gout, dealt with the topic
how to differentiate gout tophi from rheumatoid nodules (12). Tophi generally appear hyper-echoic and
cloudy with partial or complete posterior shadowing. They are heterogeneous and often have poorly defined
contours. They are surrounded by an anechoic halo (13). Tophi may lead to erosions of the underlying bone.
Rheumatoid nodules are typically not erosive to bone. They are sharply demarcated, homogeneous and hypo-
echoic with few or no colour Doppler signals (Figure 31). There is no posterior shadowing, so that cortical bone
can be easily seen (14).

2007-2015 EULAR 3
Anatomy images by Sonoanatomy Group - Barcelona University
 Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 31. Ultrasound image of a rheumatoid nodule (longitudinal plane at the forearm). The power Doppler
mode does not show any signals.

Ultrasound may also reveal intra-articular crystal deposits that have the same appearance (15). In addition,
crystal deposits upon the cartilage form a hyper-echoic, slightly irregular line that runs parallel to the cartilage
and bone surface (double contour sign) (16,17).

Moreover, ultrasound can aid in detecting fluid that can be aspirated for further diagnostic testing.

Ultrasound is a valuable tool to distinguish between gout and rheumatoid arthritis.

2007-2015 EULAR 4
Anatomy images by Sonoanatomy Group - Barcelona University