S46 Ultrasound in Medicine & Biology
GBP of 7-9 mm: Follow-up after 12 and 36 months is recommended. ultrasound if a symptomatic approach is used, thereby expediting diagno-
If (during the follow-up period) the GBP size increases 2 mm or if
the GBP size reaches 10 mm, surgical treatment (cholecystectomy) is
recommended.
GBP of 6 mm and less: No treatment or follow-up is recommended.
SESSION 9I: PAEDIATRICS - MSK
To Graf or not to Graf: Paediatric hip ultrasound
Cain Brockely
Chief Sonographer, Royal Children’s Hospital, Melbourne, VIC,
Australia
Sonography is the imaging of choice for the initial assessment of a
patient who presents with suspected developmental dysplasia of the
hip (DDH).
DDH is a condition that results in abnormal development of the
femoral head and acetabulum. When detected early using ultrasound
the condition is easily treated via non-invasive bracing of the legs to
enable the acetabular cartilage to mold and develop over a period of
months until normal. A late detection or missed DDH can result in
the need for surgery and therefore the potential for early onset osteo-
arthritis later in life.
Ultrasound has proven to be a great screening resource for DDH
however it is known to be extremely operator dependent. It is therefore
very important that sonographers ensure they know the techniques,
diagnostic criteria and classifications, as well as pitfalls when perform-
ing hip sonography.
One such pitfall I have seen over the years is the incorrect use of the
Graf classification. Graf angles and diagnostic criteria are extremely use-
ful in the diagnosis and follow up of DDH if utilized and applied cor-
rectly. This presentation will demonstrate how to focus on technique and
landmarks, when and how to apply Graf’s diagnostic measurements, and
most importantly how to avoid the common pitfalls.
Ultrasound in hip pain - What else to look for
Lino Piotto
Tutor Sonographer, Women’s and Children’s Hospital, Adelaide, SA,
Australia
When investigating hip pain it is important to have a symptomatic
approach. Infants are generally not able to be specific about where their
pain is originating from and they are unreliable historians. Signs of hip
pathology include not weight bearing, walking with a limp and reduced
joint movement. The most common cause of hip pain is transient synovitis
which may occur following viral infection, allergic reaction or trauma, but
is usually of unknown aetiology. Other pathologies to consider are hae-
marthrosis, septic arthritis, Perthes disease, slipped capital femoral epiphy-
sis and juvenile rheumatoid arthritis. Ultrasound scanning of the hip is best
achieved from the anterior approach to assess the synovial capsule. Com-
parison views are very useful. In the event that the hip joint is normal it is
important to remember that there are many other causes of hip symptoms
and that any pathological process that involves one of the muscles that
control the hip joint may present with signs and /or symptoms suggestive
of hip joint disease. Possible pathologies include myositis, bleed, abscess
tumour and avulsion. In the absence of primary hip or surrounding muscle
pathology the examination should be extended to look for other disease
processes which may explain the signs because of their secondary effects
on muscles. Such pathologies include appendicitis, pelvic pathology,
pyelonephritis, discitis, osteomyelitis, lymphadenopathy or tumour. In the
toddler age group two additional diagnoses should be considered, a lower
limb fracture and neuroblastoma with secondary involvement of the hip
joint. In summary, remember that not all hip pain or hip symptoms relate
to the joint itself. All of these can be diagnosed at the time of a hip
Volume 45, Number S1, 2019
sis and appropriate treatment.
SESSION 10A: MSK & RHEUMATOLOGY
Tendon and muscle imaging in sports injuries
Claudia Weidekamm
Consultant Radiologist, WDHB Auckland, Auckland, New Zealand
Imaging modalities demonstrate a specific pattern for sports injuries
that is related to the biomechanical impact. The concept of the musculo-
tendino-osseous chain was developed for sports injuries and is helpful to
understand the expected injury pattern of the musculoskeletal system. At
up to 55%, the incidence of muscle lesions in acute and chronic sports
injuries is relatively high and mainly involve the hip and pelvis. In adoles-
cence injury of the apophysis is common, whereas in younger patients
musculotendinous injuries appear. Ultrasound is recommended for assess-
ment of muscle haematoma or seroma, and partial or full thickness tears
of the muscles and tendons. In particular the evaluation of the integrity of
the musculotendinous unit or muscle hernia is a strength of ultrasound.
Magnetic Resonance Imaging is superior in hyperacute muscle injuries
and delayed onset muscle soreness.
Learning objectives:
1. Impact of ultrasound for imaging musculotendinous injuries.
2. Interpretation and differential diagnosis in acute and chronic trauma.
3. Concept of musculo-tendinous-osseous chain.
4. Typical injury patterns in sports injuries.
DOMS
Susan Diep
Sonographer, I-MED, Melbourne, VIC, Australia
Delayed-onset muscle soreness (DOMS) is familiar experience for
athletes and sportsmen and women. It typically presents with swelling,
muscle tightness, aching pain, or muscle tenderness. However, this
condition is not only limited to the elite athlete demographics, but can
also be present in the general population.
DOMS is not an acute diagnosis. It typically presents 24 hours after
repetitive, strenuous exercise and peaks within 24-72 hours. The time
of onset and the time from exercise is crucial in the diagnosis of
DOMS, as by day 5 to 7, the patient’s symptoms may resolve.
The main cause of DOMS is repetitive eccentric forces which
require muscle fibres to lengthen and stretch. Muscle groups that are
unaccustomed to this amount of force for a prolonged period of time
will suffer trauma. The muscle fibres will undergo microtears on a cel-
lular level that are not detectable with conventional ultrasound, how-
ever, the overall appearance of the muscle will appear different in size,
echogenicity and texture which can be seen on ultrasound.
The extension of the sonographer’s role is to take comprehensive clini-
cal history. This is the key to diagnosis and patient management.
Although, there are many differential diagnoses for muscle pain, noting
the mechanism of injury plus the time and duration of exercise and will
ultimately guide radiologist’s to use DOMS diagnosis appropriately.
There are many methods that have been proposed to assess DOMS,
including the use of ultrasound, shearwave elastography, MRI and
some requiring blood samples. Some may say the ultrasound diagnosis
is subjective but it should be encouraged that all sonographers docu-
ment the changes to the muscular fibrillar patterns.
It is important to develop a framework in order to assess for and
document the presence of DOMS with ultrasound. The consistency
will allow for future assessment in order to discuss changes or
improvement to the musculature. With the presence of evolving tech-
nology, such as shearwave elastography, sonographers can further
quantify the degree of “damage” or “improvement”.