Matthew P. Lungren Michael R.B. Evans Editors Pediatric Clinical Medicine Musculoskeletal Covertemplate Ultrasonography YSausbsteitrl eE lf Mori edany ECdliintoicra l Medicine Covers T3_HB Second Edition 112323 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 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland 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 xi 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