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 II

Ultrasound in infectious (septic) arthritis

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

A 60-year old male presents at the emergency room with a swollen, red, hot and painful right elbow. The patient
further reports fever (38.7°C) last night. The CRP level is 240 mg/l (normal < 5.0 mg/l). Figure 37 shows an
ultrasound image of the patient’s olecranon fossa. It is filled with anechoic and hypoechoic material. Colour
signals in the hypoechoic area represent hyper-vascularization. In the centre appears an anechoic region
representing fluid. The fluid was aspirated with ultrasound guidance revealing pus. The culture of this aspirate
was positive for staphylococcus aureus.

Figure 37. Posterior longitudinal view of the elbow with effusion (anechoic area in the centre of the olecranon
fossa) and synovitis (hypoechoic structures) with hyperperfusion (positive colour Doppler signals)

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

Ultrasound allows visualizing smaller and larger amounts of fluid or synovitis in the elbow joint. Fluid can be
particularly seen in the olecranon fossa which communicates directly with the elbow joint (see right side of the
ultrasound image in Figure 37). Abnormal fluid also often occurs in the anterior parts of the joint, eg. the radial
or the coronoid fossa. Larger effusions also extend to the lateral and medial aspects of the joint.

A score has been proposed for differentiating mild (grade 1), moderate (grade 2) and severe (grade 3) synovitis
(18). In the anterior longitudinal view, a grade 1 synovitis is characterized by a joint capsule which is pushed up,
but it runs parallel to the bone (Figure 38). In grade 2 synovitis, the capsule is no longer parallel to the bone but
runs in a straight line (Figure 39). In grade 3 synovitis, the capsule has a convex configuration (Figure 40). The
olecranon fossa is partly filled in grade 1 synovitis (Figure 41), completely filled in grade 2 synovitis (Figure 37),
and the synovitis extends over the limits of the fossa in grade 3 (Figure 42).

Figure 38. Mild synovitis (grade 1) with the joint capsule parallel to the bone surface (anterior longitudinal
view of the elbow)

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

Figure 39. Moderate synovitis (grade 2) with the joint capsule running straight and not parallel to the bone
(anterior longitudinal view of the elbow)

Figure 40. Severe synovitis (grade 3) with a convex configuration of the joint capsule (anterior longitudinal
view of the elbow)

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

Figure 41. Mild synovitis (grade 1) with partially filled olecranon fossa (posterior longitudinal scan)

Figure 42. Severe synovitis (grade 3) with synovial material extending over the limits of the olecranon fossa
(posterior longitudinal scan)

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

Ultrasound particularly allows us to find small amounts of fluid in the elbow joint. This fluid can be aspirated
with ultrasound guidance in order to confirm the final diagnosis (19). Several diseases such as infectious (septic)
arthritis, crystal arthritis (gout, pseudogout, or hydroxyapatite deposition disease), or other arthritide,
particularly reactive arthritis, can be the cause of acute hot, red and painful elbow swelling. In infectious arthritis,
the cell count in the aspirated fluid is usually strongly elevated with a high percentage of granulocytes.
Polarization microscopy, gram stain and bacterial culture help to confirm the final diagnosis.

Only few articles have been published on ultrasound in septic elbow arthritis, particularly in children (20, 21).
However, infectious arthritis of the elbow can occur in rheumatological practice. It may exist either in the elbow
joint itself or in the olecranon bursa. Often, hyper-echoic particles become visible next to the effusion. These
particles fluctuate when compressing the effusion with the ultrasound probe or displacing the fluid with the
probe or with the hand of the examiner. No imaging modality provides specific findings for septic arthritis. The
rheumatologist needs to rely on aspiration of the fluid and further diagnostic tests. Nevertheless, ultrasound
can be very helpful in the diagnosis of acute or chronic swelling of the elbow.

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Anatomy images by Sonoanatomy Group - Barcelona University