Post on 08-Feb-2021
어깨 초음파 스캔(정상 소견 및 증례)
창원경상대학교병원
김현옥
Contents
List Structures
1 Normal anatomy of shoulder joint
2 Biceps tendon
3 Subscapularis tendon
4 Supraspinatus tendon
5 Infraspinatus tendon
6 A-C joint
7 Cases
Normal Anatomy of Shoulder Joint
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Diagnostic Ultrasound Musculoskeletal ELSEVIER
1 2
3
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Rotator cuff muscle
Rotator cuff musclesMuscle Origin on
scapulaAttachment onhumerous
Function
Infraspinatusmuscle
Infraspinatusfossa
Posterior facet of the GT
Externally rotates the arm
Supraspinatusmuscle
Supraspinatusfossa
Superior and middle facet of the GT
Abducts the arms
Subscapularismuscle
Subscapularfossa
Lesser tuberosity or humeral neck
Internally rotates the humerus
Teres minor muscle
Middle half oflateral border
Inferior facet of the GT Externally rotates the arm
Basic View
• 1. Biceps tendon (long head)- transverse/longitudinal
• 2. Subscapularis tendon- transverse/longitudinal
• 3. Supraspinatus tendon- transverse/longitudinal
• 4. infraspinatus tendon- transverse/longitudinal
Biceps tendon
Biceps tendon
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Biceps tendon
Acta Radiol. 2013 Feb 1;54(1):83-8. doi: 10.1258/ar.2012.120353.
Biceps tendon, short head
Biceps tendon, long head
https://www.google.co.kr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjRyYX2r_XeAhVFXLwKHWjsBq8QjRx6BAgBEAU&url=https://www.researchgate.net/figure/nsertion-of-the-subscapularis-SSC-coracohumeral-ligament-and-supraspinatus-SSP-on_fig3_232649229&psig=AOvVaw0bNtgSbtTJI8kQRkAD7ojQ&ust=1543435621934604
Biceps tendon: transeverse
Fundamentals of Musculoskeletal Ultrasound
비등방성(anisotropy)
Fundamentals of Musculoskeletal Ultrasound
Biceps tendon: longitudinal
비등방성(anisotropy)
Lesser tubercle
Deltoid muscle
Subscapularis tendon
Subscapularis tendon
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Subscapularis tendon: longitudinal
Fundamentals of Musculoskeletal Ultrasound
Lesser tubercle
Subscapularis tendon
Subscapularis tendon: transverse
Fundamentals of Musculoskeletal Ultrasound
Hyperechoic tendon bundle
Hypoechoic muscle (arrowheads)
Supraspinatus tendon
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Supraspinatus tendon (Neutral position)
Fundamentals of Musculoskeletal Ultrasound
Acromion
Greater tubercle
Humeral head
Supraspinatus tendon
Deltoid
Humeral head
Supraspinatus evaluation: Crass Position
Supraspinatus tendon (longitudinal)
Fundamentals of Musculoskeletal Ultrasound
Deltoid
Supraspinatus tendon (longitudinal)
Fundamentals of Musculoskeletal Ultrasound
비등방성(anisotropy)
Supraspinatus tendon (transeverse)
https://cbsnewyork.files.wordpress.com/2017/05/rotatorcuff.jpg
Supraspinatus tendon (transeverse)
Fundamentals of Musculoskeletal Ultrasound
Deltoid
Supraspinatus and infraspinatus junction
(open arrow)
Supraspinatus tendon(arrow)
Practical Musculoskeletal Ultrasound
Supraspinatus and infraspinatus junction
Infraspinatus tendon
Diagnostic Ultrasound Musculoskeletal ELSEVIER
Infraspinatus tendon
Fundamentals of Musculoskeletal Ultrasound
Infraspinatus tendon: transverse
www.med.umich.edu
GL
deltoid m.
Infraspinatus
www.med.umich.edu
GL
Infraspinatus
Infraspinatus tendon: Longitudinal
Infraspinatus tendon: normal view
www.med.umich.edu
Transverse view Longitudinal view
Acromioclavicular joint
Acromioclavicular joint
Practical Musculoskeletal Ultrasound
Cases
Supraspinatus tears
Supraspinatus tendon tear
• Supraspiantus: initial abduction (no rotation)
- involved in 95% of rotator cuff tears (alone or with adjacent infraspinatus or subscaplaris tendon tear)
• Painful arc of motion: pain with active range of motion between 60~120° of abduction is associated with rotator cuff disease
• Passive range of motion (+) : rotator cuff disease VS adhesive capsulitis
• Empty can test
https://www.clinicalkey.com
Supraspinatus tendon tear
• Supraspinatus tendon tear (by tear thickness)
• Partial-thicknessBursal
Articular
Intrasubstance (intratendinosus)
• Full-thickness
Supraspinatus tendon tear
• Ultrasound findings
1) Tendon thinning
2) Cortical irregularity
3) Joint effusion and bursal fluid
4) Cartilage interface sign
Supraspinatus tendon tear: articular type
Fundamentals of Musculoskeletal Ultrasound
Contact with the articular surface (arrow) Cortical irregularity of the
greater tubercle (arrowhead)
Well defined anechoic disruption of the tendon fiber
(curved arrow)
Supraspinatus tendon tear: bursal tear
Fundamentals of Musculoskeletal Ultrasound
Supraspinatus tendon tear: intrasubstance tear
Fundamentals of Musculoskeletal Ultrasound
Supraspinatus tendon tear : full thickness tear, focal
Fundamentals of Musculoskeletal Ultrasound
Cartilage interface sign (arrowheads)
Subdeltoid bursa(open arrow)
Supraspinatus tendon tear
Fundamentals of Musculoskeletal Ultrasound
Articular tear
Supraspinatus tendon tear
Fundamentals of Musculoskeletal Ultrasound
Bursal tear
Supraspinatus tendon tear : full thickness tear
Fundamentals of Musculoskeletal Ultrasound
Full thickness, complete tear
Anechoic disruption of the tendon fiber(curved arrow)
Proximal tendon retraction(arrow)
Supraspinatus tendinosis
• Tendinosis (or tendinopathy)
1) corresonding to tendon degeneration without inflammation.
2) a heterogeneous, somewhat ill defined, hypoechoic area in the tendon without a tendon defect.
Fundamentals of Musculoskeletal Ultrasound
Supraspinatus tendinosis
Fundamentals of Musculoskeletal Ultrasound
Biceps tendinitis
• 위팔두갈래힘줄염(Biceps tendinitis) 임상 증상
• 어깨의 앞쪽에 발생하는 통증이 특징적임(가끔 어깨 전체도 나타남)
• 위팔두갈래근 힘줄윤활막염(tenosynovitis of biceps tendon)과 잘 동반됨
• Speed test and Yergason’s test
KCR textbook of Rheumatology 2nd
Biceps tendinitis
Biceps tendinitis
Popeye sign (biceps tendon tear)
N ENGL J MED 2017; 377:1976
https://radiopaedia.org/cases/long-head-of-biceps-tendon-tear-1
Tendon calcification
•임상 증상• Rotator cuff tear 혹은 impingement syndrome과 유사함
• 외상이 없이 점진적으로 나타나기도 함
• 야간에 통증이 증가, 아픈 쪽으로 누워 자기 힘듬
• 머리위로 손을 올리는 동작을 하는 경우 통증이 동반됨
• 일부에는 3~6개월 뒤에 저절로 호전됨
• 약 30%정도의 환자는 만성적인 경과를 보임
Tendon calcification
• Calcific deposits within the rotator cuff may take one of two forms
1. Degenerative calcification2. Calcium hydroxyapatite deposition
• Calcific tendinitis: the presence of inflammatory markers
-> active and passive range of motion may be limited
(may be warm and tender)
• Calcific tendinosis: a reported prevalence of 24% of asymptomatic females
• Supraspinatus is most commonly involved
Fundamentals of Musculoskeletal Ultrasound
Tendon calcification
• The calcific deposits in calcific tendinosis most commonly are hyperechoic with posterior acoustic shadowing
• Cortical erosions and osseous involvement may also be present
• In approximately 7% of cases, tendon calcification shadowing is absent, and radiographs may be normal (if calcifications are in the form of a thick fluid or slurry)
Fundamentals of Musculoskeletal Ultrasound
Calcific tendinitis- supraspinatus tendon
https://radiopaedia.org/articles/calcific-tendinitis?lang=us
Diagnostic Ultrasound: Musculoskeletal
Calcific tendinitis- supraspinatus tendon
Fundamentals of Musculoskeletal Ultrasound
Impingement syndrome
• 임상 증상
• Rotator cuff tendinopathy와 증상이 유사함
• 머리 위로 손을 올리게 되면 통증이 동반됨
• Deltoid area와 lateral arm에 통증이 있음
• 야간 및 통증이 있는 부위로 눕기 힘듬
• 이학적 검사
• Painful arc
• Neer’s test
• Hawkin’s sign
Shoulder impingement syndrome
https://www.rehabmypatient.com/shoulder/shoulder-impingement-syndrome
Fundamentals of Musculoskeletal Ultrasound
Shoulder impingement syndrome
Fundamentals of Musculoskeletal Ultrasound
The Egyptian Journal of Radiology and Nuclear Medicine (2014)45, 1171–1182
Shoulder impingement syndrome
Supraspinatustendon
Supraspinatustendon
AcromionAcromionAcromion
Greatertubercle
Greatertubercle
SASD bursitis
Glenohumeral joint effusion
Fundamentals of Musculoskeletal Ultrasound
www.med.umich.edu
Infraspinatus
Humerous
부종, 열감, 경직감, 통증
Shoulder Injection
https://musculoskeletalkey.com/ultrasound-guided-interventional-procedures-about-the-shoulder/
https://www.youtube.com/watch?v=OAeOEc-X0kU
https://musculoskeletalkey.com/ultrasound-guided-interventional-
Take home message
•정확한 진단을 위해서는 병력 청취가 중요합니다
•정상 구조물에 대한 숙지가 중요합니다
•정상 구조물을 바탕으로 pathologic finding을 감별 할 수 있어야 합니다
감사합니다