Uvod v MSK ultrazvok - Randy Moore

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A Primer of Basic Musculoskeletal Images | Randy E. Moore 1

Introduction to

MusculoskeletalUltrasound Imaging

Randy E. Moore, DC RDMS - www.mskmasters.com



Musculoskeletal sonography is well on its way tobeing accepted as “standard of care” in physical

medicine.

In the past few years, the most prominent

interest in this imaging modality has shifted from a need to visualize the “current physiologic

state” of the tissue, to accurate placement of

medication, and needle visualization.

The pre-requisite to identifying pathology, and

using ultrasound for injection guidance is todevelop the skill to accurately and eciently

identify normal musculoskeletal anatomy during

ultrasound examination.

Randy E. Moore, DC, RDMS



A Primer of Basic Musculoskeletal Images | Randy E. Moore3

Table of Contents

Chapter 1 - Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2 - Guidelines for Musculoskeletal Sonography . . . . . . . . . . . . . . . . 7

Chapter 3 - Basic Normal Musculoskeletal Ultrasound Anatomy . . . . . . . .11

Chapter 4 - The Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Biceps Tendon Short Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Biceps Tendon Long Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Anterior Rotator Cu: Supraspinatus Tendon Short Axis . . . . . . . . . . . . . . . . 18

Anterior Rotator Cu: Supraspinatus Tendon Long Axis . . . . . . . . . . . . . . . . 19

Gleno-humeral Intrarticular Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Chapter 5 - The Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Lateral Epicondyle Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Medial Epicondyle Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 6 - The Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Palmar Transverse Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Dorsal Metacarpal-Phalangeal Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 7 - The Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Quadriceps Tendon Long Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Chapter 8 - The Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Plantar Fascia Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32



Chapter 1Introduction




“Ultrasound imaging is not a passive push-button activity; rather it is

an interactive process involving a skilled clinician, patient, transducer,

instrument, and experienced interpreter. Understanding the physical

principles involved contributes to the quality of medical care involving

diagnostic sonography”

IntroductionDiagnostic ultrasonography as a general medical imaging modality has made

very great advances in the last 10 to 20 years within the medical profession.Now, appearing on the horizon, is the more frequent application of diagnostic

ultrasound to image musculoskeletal structures and the extremities of the body.

This manual is intended to provide an introduction to musculoskeletal scanning

protocols of the extremities, and hands-on use of diagnostic ultrasound.

The protocols presented are intended to provide a foundation from which

physicians and technologists can develop more advanced ultrasound scanning

abilities through education and experience in musculoskeletal ultrasound.

Sonography’s unique real-time capability, which permits examination during

movement, and allows guidance of biopsy needles, combined with the exquisite

resolution of state-of-the-art scanners and high-frequency transducers, makes

musculoskeletal sonography a powerful tool for diagnosing abnormalities of

the soft tissues. Musculoskeletal sonography has been underused because

of the availability of magnetic resonance imaging. However, sonography can

provide diagnostic information for only a fraction of the cost. In this era of costcontainment in health care, musculoskeletal sonography should be the rst

examination technique for many pathologic conditions of the soft tissues.

I feel condent that these protocols will provide physicians information to

improve evaluation and treatment of patients through valuable diagnostic

information obtained from the images.

1 | Introduction



Chapter 2Suggested Guidelines forMusculoskeletal Sonography




2 | Suggested Guidelines for Musculoskeletal Sonography

Equipment SelectionMusculoskeletal structures are long, striated and many times

layered tissues. Due to the striated morphology of these tissues

and their supercial location, high frequency, linear array

transducers are best suited for this application. It is recommended

that no less than 7.5 MHz transducers be used for musculoskeletal

examinations of the extremities. Ideally, 8.0 MHz and above

provide the highest resolution.

As in all ultrasound examinations, proper technical settings are

vital to the diagnostic value of the images. Musculoskeletal

images require adequate grayscale. Limited grayscale can lead

to diagnostic challenges. Refer to the manufacturer of yourequipment and their specic guidelines for optimal image settings.

Probe PlacementIt is very important to maintain accurate transducers placement in

musculoskeletal sonography. Due to the close proximity of several

distinct structures in a small area, a slight displacement of the

probe can produce inaccurate images. If the image states it is a

“midline” image be sure to be as close to midline as possible.

Image OrientationImage orientation is consistent throughout the manual.

Regardless of right or left.

Longitudinal views: left side of the image is CEPHALAD.

Transverse views: left side of the image is the PATIENT’S RIGHT

Suggested Exam ProtocolThe photographs in the manual clearly indicate patient and probe

positioning. All examinations do not need to be bilateral studies

that include identical images. It is not necessary to perform all

images described for each extremity in this manual on every

examination. Images may be performed specically in the area

of complaint. However, we recommend no less than 6 images per

exam. 3 transverse images and 3 longitudinal images.

Tips For Clinicians

Optimize your system for

proper grayscale. Almost all

images have identiable bo

landmarks. Visualize the bon

landmarks and the surroundi

soft tissue should also be

visible. Labeling of images

in this manual are merely

suggestions. Feel free to

establish a system of

labeling of images that is

best for your facility. To avoi

confusion, take care not to

make abbreviations too shor



3 Steps to

Successful Imaging

2 | Suggested Guidelines for Musculoskeletal Sonography


Good images are aprerequisite for excellent

guided injections

1. Image GENERATION Patient & probe position, grayscale settings

2. Image RECOGNITION Identify Individual Interfaces from the bony cortex UP

to the skin surface!

3. Image INTERPRETATION Determine abnormal ndings by knowing normal!

Using a systematic,

STANDARDIZED approach

lets the clinician obtain

highly accurate anatomic

representation of the

anatomy.

The anticipated length

of the “learning curve” is

shortened. Confdence and

expertise is gained in a

shorter time frame.



Chapter 3Basic Normal MusculoskeletalUltrasound Anatomy



3 | Basic Normal Musculoskeletal Ultrasound Anatomy


Skeletal Muscle

On longitudinal views, the muscle septae

appear as bright/echogenic structures, and are

seen as thin bright linear bands. On transverse

views, the muscle bundles appear as speckled

echoes with short, curvilinear bright lines

dispersed throughout the darker/hypoechoic

background.

Subcutaneous TissueSubcutaneous tissue is isoechoic (equal

brightness) with skeletal muscle. The dierence

between subcutaneous tissue and skeletal

muscle visualized on ultrasound is the septa do

not lay in lines or layers. More conspicuously;

a thick, continuous, hyperechoic band usually

separates subcutaneous fat from muscle.

Cortical Bone

On ultrasound examination, normal cortical

bone appears as a continuous echogenic (bright)

line with posterior acoustic shadowing (black).

Fascia

Fascia is a collagenous structure that usually

surrounds the musculotendinous areas of the

extremities. The fascia is then encompassed

subcutaneous tissue. Many times, the fascia i

seen inserting onto bone, and blending with t

periosteum. Normal fascia appears as a brou

bright/hyperechoic structure.

PeriosteumOccasionally, a thin echogenic line running

parallel with the cortical bone is demonstrate

on ultrasound. This is likely the periosteum.

However, in normal situations, the periosteum

is not visualized by ultrasound. Injuries to the

bone, especially those damaging the cortex,

periosseous soft tissues, and periosteum will

produce a periosteal reaction, which is visible

The following is a very basic introduction to normal

musculoskeletal anatomy on ultrasound, which is intended to

get novices started scanning quickly. For in-depth knowledge ofnormal and abnormal musculoskeletal anatomy, please consult one

of the many comprehensive textbooks on ultrasound examination

that are readily available.



3 | Basic Normal Musculoskeletal Ultrasound Anatomy


Ligaments

On ultrasound examination, a normal ligament

is also a bright echogenic linear structure.

However ligaments have a more compact

brillar echotexture. Individual strands/bers

of the ligaments are more closely aligned.

Ligaments are composed of dense connective

tissue, like tendons, but there is much variability

in the amounts of collagen, elastin and

brocartilage within a ligament, which makes

its ultrasound appearance more variable than

tendons.

Bursae

In a normal joint, the bursa is a thin black/anechoic line no more than 2 mm thick. The

bursa lls with uid due to irritation or

infection. Depending on the extent of eusion,

the bursa will distend and enlarge; internal

brightness echoes are inammatory debris.

Peripheral Nerves

High-frequency transducers allow the

visualization of peripheral nerves that pass

close to the skin surface. Peripheral nerves

appear as parallel hyperechoic lines with

hypoechoic separations between them.

On longitudinal views, their appearance is

similar to tendons, but less bright/echogenic.

On transverse views, the peripheral nerves’

individual bers, and brous matrix, present

with multiple, punctate echogenicities

(bright dots) within an ovoid, well-dened

nerve sheath.

Tendons

A normal tendon on ultrasound examination is

a bright/echogenic linear band that can vary in

thickness according to its location. The internalechoes are described characteristically as

having a brillar echotexture on longitudinal

views. On ultrasound the parallel series of

collagen bers are hyperechoic, separated by

darker/hypoechoic surrounding connective

tissue. The bers will be continuous/intact.

Interruptions in tendon bers are visualized

as anechoic/black areas within the tendon.

Tendons are known to be anisotropic structures.

An / iso / tropy.

To not have equal properties/

characteristics/ appearances on all

axes. The property of being directiona

dependent. Produced when the probe

is not perpendicular with the structur

being evaluated. Most common artifa

in musculoskeletal ultrasound.

Anisotropy:

Denitions



Chapter 4The Shoulder



4 | Shoulder - Biceps Tendon Short Axis


Biceps TendonShort Axis“Home Base”

The patient is seated with the

arm resting close to the side, and

the elbow is bent at 90 degrees,

resting on the patient’s lap.

The palm is turned up; but not

actively. Sometimes a pillow

is helpful when placed on the

patient’s lap.

Place the mid portion of the probe

in transverse orientation over

the PROXIMAL biceps region. By

carefully aiming the sound beam

the bright/echogenic contour of the

humeral head will become visible

Visualize the tendon within thebicipital groove.

LABELING: BIC SAX

Fig. 1 - Patient and probe position Fig. 2

Fig. 3 - SAX Biceps Tendon.

Greater Tuberosity

Humerus



4 | Shoulder - Biceps Tendon Long Axis


Biceps TendonLong Axis

1. The biceps tendon is

examined in the longitudinal

orientation. Patient

positioning is unchanged

(seated with the arm relaxed

and the elbow exed).

2. From the proximal short axis

position, rotate the probe 90degrees. Align the humeral

cortex across the image.

3. Typically, medial translation

of the probe will visualize the

biceps tendon

LABELING: BIC LAX

Fig. 3 - Biceps Tendon Long Axis View.

Fig. 1 - Patient and probe position. Fig. 2

Humerus



4 | Shoulder - Anterior Rotator Cu: Supraspinatus Tendon Short Axis


AnteriorRotator Cuf:

SupraspinatusTendon Short Axis

1. Place the probe in the

short axis orientation at

approximately the mid portion

of the humeral head. The

Supraspinatus is best seen

when the probe is parallel

with the oor.

2. The broad “dome-like”

convexity of the humerus

is identied.

Then the anechoic hyaline

cartilage covering the

humerus.

The thick/wide, bright/

echogenic arc is the brillar

pattern of the supraspinatus

tendon.

The thin/slender, dark/

anechoic area just above the

tendon is the subdeltoid/subacromial bursa in its

normal state.

LABELING: SSP SAX

A. Humeral Cortex

C. Supraspinatus Tendon

B. Hyaline Cartilage

D. Bursal Interface betweentendon & muscle

Fig. 3: Supraspinatus Short Axis

Individual - Interface - Identication

Fig. 1 - Patient and probe position. Fig. 2 - Arrows indicateSupraspinatus tendon.

D

C

B

A



4 | Shoulder - Anterior Rotator Cu: Supraspinatus Tendon Long Axis


AnteriorRotator Cuf:

SupraspinatusTendon Long AxisThe “Two Part” Landmark

1. From the anterior short axis

position, rotate the probe to

be parallel with the humeral

shaft.

2. IMPORTANT! The “two

part “ landmark of the

greater tuberosity and

the humeral head ensure

adequate visualization of the

supraspinatus attachment

3. Viewing the image from left

to right, the supraspinatus

tendon resembles a “bird’s

beak”. The point of the “beak’

is the insertion of the tendon

onto the greater tuberosity of

the humerus. The anechoic/

black area on the attachment

surface is the tendon

“footprint”, which is normal.

* The “Critical Zone” is the 1

cm attachment area of the

supraspinatus tendon, where

90% of all rotator cu tears

are found.

LABELING: SSP LONG

Tendon “footprint”

Greater Tuberosity /Tendon Attachment

Humeral Head

Fig. 1 - Probe parallel to Humeral shaft. Fig. 2 - Arrows indicateSupraspinatus tendon.

Fig. 3 - Supraspinatus Long Axis.



4 | Shoulder - Gleno-humeral Intrarticular Injection

Gleno-Humeral Joint


Gleno-humeralIntrarticular

InjectionPosterior Approach

1. The patient is in side posture

with the arm in full adduction

and internal rotation to

expose the posterior gleno-

humeral joint and labrum.

2. Position the probe in

a transverse/oblique

orientation, and slide it

inferior and medially toward

the axilla.

3. Inferior to superior probe

angle with adequate probe

pressure is necessary to

visualize the gleno-humeral

joint .

LABELING: POST GH SAX

Patient Position: Sideposture Internal rotationwith adduction

(A) Inf. GH Ligament(B) Axillary Pouch of GHL

Note SUPERIOR locationof Joint Capsule (C)relative to IGL

Glenoid Fossa

CA

B

Humerus GlenoidFossa



Chapter 5The Elbow



5 | Elbow - Lateral Epicondyle Long Axis


Lateral EpicondyleLong Axis

1. Position the probe out on the

lateral aspect of the elbow in

long axis.

The bony landmarks are the

capitellum of the humerus

(proximal), and the radial

head (distal).

There should be a slight

exion of the elbow.

2. Just above the capitellum is

the insertion of the common

forearm extensor tendon, on

the lateral epicondyle.

LABELING: LAT EPI LAX

Fig. 1 - Longitudinal probe position onlateral elbow at the epicondyle.

Fig. 2 - The common extensor attachessuperior/proximal to capitellum.

Fig. 4 - Injection Setup. Fig. 5 - Example Procedure.

Fig. 3 - Common extensor tapers to its attachment on the lateral epicondyle which isproximal to the capitellum of the humerus.

Radial HeadHumerus

CommonExtensor



5 | Elbow - Medial Epicondyle Long Axis


Medial EpicondyleLong Axis

1. The elbow is exed and arm

externally rotated.

The hand is actively

supinated. Ask the patient to

turn the palm up.

2. Place the probe in a

longitudinal plane on the

medial side of the elbow. Theproximal end of the probe is

then angled down towards the

table. The UCL should be

well visualized.

3. The common exor tendon

converges to attach on the

medial epicondyle.

LABELING: MED EPI LAX

Fig. 1 - Longitudinal probe position onmedial aspect with supination.

Fig. 2 A direct medial to lateral view ofthe medial epicondyle.

Fig. 3 - The thick, brous linear band of the common forearm exor is seen supercialthe triangular shaped ulnar collateral ligament.

UCL

Humerus

Ulna



Chapter 6The Wrist



6 | Wrist - Palmar Transverse Wrist


Palmar TransverseWrist

1. The patient’s wrist is in a neut

position with the palm up. Usi

a cushion allows the wrist to

be relaxed.

2. Place the probe in short axis

across the wrist at the “CREAS

with the radial side being

the left side of the image.Use light probe pressure to

avoid compressing the nearly

subcutaneous nerve.

3. The exor tendons are in

compartments. They appear a

echogenic ovoid structures on

transverse examination.

4. The median nerve is supercia

to the exor pollicis longus

tendon, and distinguishable

by identifying its punctate /

pinpoint internal echoes. ie:

“starry night” or “honeycomb”

description.

5. Slowly ex the thumb, and

look for tendon movement. Th

median nerve will be superc

and to the right of the FPL.

LABELING: MN SAX

Fig. 1 - Supported wristNeutral position.

Fig. 2 - Median nerve is located toward theRadial aspect.

Fig. 3 - Ask patient to ex the thumb. Median nerve (MN) is above and right of theexor pollicis (FPL). Visualize bright, punctuate foci of nerve bers. “Starry Night.”

Median Nerve

RAD ULN



6 | Wrist - Dorsal Metacarpal-Phalangeal Long Axis


Dorsal Metacarpal-Phalangeal LongAxis

A.K.A. MCP Joints Carpal-Metacarpal Joint

1. Place the probe in the

longitudinal plane over the MC

joint of interest.

The metacarpal head is rounde

with a NORMALLY occurring“notch” proximal to the joint.

2. The MCP Joint is frequently

aected in rheumatoid arthrit

as well as the PIP Joint.

Joint eusions, synovitis,

soft-tissue swelling can be

easily detected and monitored

with ultrasound. Cortical

erosions of the MCP Joint will

be plainly evident.

LABELING: DOR MCP LAX

Fig. 1 - Supported wrist Neutral position.

Fig. 2 - Longitudinal image of dorsal MCP. Yellow Arrow: normal cortical margin.

Fig. 3 - Out of PlaneInjection.

Fig. 4 - Tip of needle between arrows.

ProximalPhalanxDistal

Metacarpal



Chapter 7The Knee



7 | Knee - Suprapatellar Bursa

A. Skin, subcutaneous fat, muscle

B. Quad Tendon

C. PRE-Femoral Fat Pad

D. Suprapatellar Fat Pad

E. Suprapatellar Bursa/Pouch


Quadriceps TendonLong Axis

1. The patient is supine. The pro

is in the longitudinal position

with the inferior portion in

contact with the patella. The

cortical outline of the patella i

on the right of the image, with

the femoral cortex found lowe

on the left.

2. The hyperechoic quadriceps

tendon is composed of three

superimposed layers.

3. Noting the normal presence

of two (2) fat pads (g 2),

will help the examiner

evaluate the quadriceps

tendon. The suprapatellar

bursa is continuous with the

joint capsule. It is common

site chosen for intrarticular

injection.

LABELING: QUAD LAX

Fig. 1 - Supine pt. Slight exion. Fig. 2 - Quad tendon attaches topatella. Suprapatellar bursa is deep.

Fig. 3 - The thick, echogenic tendon is the convergence of four tendons.

Fig. 4 - Needle advanced to a thin bursalinterface

B

A

E

C

D

FH

Patella

Femur



Chapter 8The Foot



8 | Foot - Plantar Fascia Long Axis


Plantar FasciaLong Axis

1. The patient is prone or kneelin

into a chair. The probe is in lon

axis, angled medially toward

the attachment onto the medi

tubercle of the calcaneous. Fig

2. Reading the image from the

cortical outline to the surface:

A. Plantar Fascia

B. Fibro Fat Pad

Musculature seen deep to

the fascia, and distal from the

calcaneous.

3. Plantar fasciitis is an extremel

common foot complaint in bot

the sporting and non-athletic

population.

LABELING : PF LAX

Fig. 1 - Prone or kneeling pt. Fig. 2 - PF attachment in green. Fat pad

supercial.

.

Fig. 3 - Long axis view of Plantar Fascia There should NOT be a bursa. Fluidaccumulation is abnormal. > 4mm thickness is criteria for fasciitis. Measurementsshould be taken at distal point of calcaneal apex.

Deep Flexors

PF

CAL

Fat Pad



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