Knee inflammation case.

[Michael Shilton]

Hi Stephen, this 84 yr old gentleman with vascular dementia presented with one week of pre patella pain. The anterior knee was red,warm and slightly swollen. Insidious onset but not reliable history due to dementia. He did present similarly to me 3 yrs ago and, as this was before my ultrasound training, I referred him to his GP to rule out infection/inflammation, I hadn’t seen him since then and he and his wife were unable to recall the outcome of this prior episode.
His x rays were clear, there appears to be inflammation in the quad tendon extending into the pre patella area. But there appears to be inflammation in the soft tissue superior to the tendon? Any thoughts? Thank you. Mike

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[Stephen Bird]

Hi Mike,

There are a few options here,

It is certainly an inflammatory condition.

The sub-cutaneous fat is really echogenic and you report that the knee is swollen, red and warm.

I agree there is increased vascularity n the quadriceps tendon and the tendon itself is more echogenic than I would expect.

The knee joint does NOT appear to have any effusion and it might be worth putting a power Doppler box into the supra patellar pouch to see if there is any knee joint synovitis. The absence of a knee joint effusion makes my think primary knee synovitis is unlikely.

So that leaves us with things that cause inflammation in the sub-cutaneous tissues superficial to the knee joint.

Pre patellar bursitis
Cellulitis
Gout
Anything else you can think of?

I include gout as this would explain the involvement of the quad tendon.

You could do some bloods

I can’t see anything that is aspiratable at this stage.

Steve.

[Michael Shilton]

Hi Steve, I was considering those differentials but I guess I was expecting to see some other ultrasound indications such as fluid for the bursitis, cobblestone appearance for cellulitis or some multi foci hyper reflectivity for gout? Presumably these don’t have to be present. Clinically I’m leaning most towards gout, I let you know if the bloods support this. Many thanks, Mike

[Stephen Bird]

I agree Mike,

Gout is the one that would explain the quad tendon appearance and local inflammation best.

Steve

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