EULAR on-line course on Ultrasound

Sonoanatomy
Scanning technique and
basic pathology of the
elbow

Wolfgang A. Schmidt, Sarah Ohrndorf, 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 right MCP 1-3, left MCP 1, 2 and 5, and both PIP 2 joints were swollen. Mobility of both
ankles and both MTP 1 joints was impaired. Figure 33 shows the patient’s left hand. CRP and ESR were elevated;
rheumatoid factor and ACPA were negative. The patient had hard nodules on the dorsal side of the forearms
below the elbow that were not displaceable (Figure 34). Uric acid levels were elevated (540 μmol/l; 9 mg/dl).
Ultrasound of the nodules revealed hyper-echoic, cloudy structures with partial dorsal shadowing (Figure 35).
Ultrasound-guided injection of saline solution allowed aspirating some drops of the installed fluid. Polarization
microscopy revealed extra- and intra-cellular sodium urate crystals.

Figure 33. Left hand of the patient with the differential diagnosis of rheumatoid arthritis or gout

©2007-2020 EULAR 2
Anatomy images by Sonoanatomy Group - Barcelona University
 Sonoanatomy Scanning technique and basic pathology of the elbow – Module 3

Figure 34. Left elbow showing a nodule of the forearm in distal position to the elbow

Figure 35. Ultrasound image of the nodule above (transverse plane to the forearm)

The rheumatologist needs to clearly differentiate between gout and rheumatoid arthritis since the management
of both diseases is considerably different. Ultrasound can easily differentiate between rheumatoid nodules and
gout tophi. In fact, the first publication, that has described the sonographic appearance of gout, discussed how
to differentiate gout tophi from rheumatoid nodules (13). 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 (12). Tophi may lead to erosions of the underlying bone. Rheumatoid
nodules do typically not lead to erosions of the bone. They are sharply demarcated, homogeneous and hypo-
echoic with few or no colour Doppler signals (Figure 36). There is no posterior shadowing, so that cortical bone
can be easily seen (14).

©2007-2020 EULAR 3
Anatomy images by Sonoanatomy Group - Barcelona University
 Sonoanatomy Scanning technique and basic pathology of the elbow – Module 3

Figure 36. Ultrasound image of a rheumatoid nodule (longitudinal plane to 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.

Therefore, ultrasound is a valuable diagnostic tool to distinguish between gout and rheumatoid arthritis.

©2007-2020 EULAR 4
Anatomy images by Sonoanatomy Group - Barcelona University