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Workbook Musculoskeletal Ultrasound September 26, 2013 Shoulder Checklist Long biceps tendon Patient position: Facing the examiner Shoulder in slight medial rotation; elbow in flexion and supination Plane/ region: Transverse (axial): from a) intraarticular portion to b) myotendinous junction (at level of the pectoralis major tendon). What you will see: Long head of the biceps tendon Supraspinatus tendon Transverse humeral ligament Subscapularis tendon Lesser tuberosity Greater tuberosity Short head of the biceps Long head of the biceps (musculotendinous junction) Humeral shaft Pectoralis major tendon Plane/ region: Logitudinal (sagittal): What you will see: Long head of biceps; fibrillar structure Lesser tuberosity Long head of the biceps tendon Notes: Subscapularis muscle and tendon Patient position: Facing the examiner Shoulder in lateral rotation; elbow in flexion/ supination Plane/ region: longitudinal (axial): full vertical width of tendon. What you will see: Subscapularis muscle, tendon, and insertion Supraspinatus tendon Coracoid process Deltoid Greater tuberosity Lesser tuberosity Notes: Do passive medial/ lateral rotation while examining Plane/ region: Transverse (sagittal): What you will see: Lesser tuberosity Fascicles of subscapularis tendon Supraspinatus tendon Patient position: Lateral to examiner Shoulder in extension and medial rotation Hand on ipsilateral buttock Plane/ region: Longitudinal (oblique sagittal) Identify the intra-articular portion of biceps LH in the transverse plane; then rotate probe until biceps LH is elongated. Supraspinatus is found by sliding laterally. What you will see: Acromion Myotendinous junction of supraspinatus Deltoid Greater tuberosity Articular cartilage Long head of the biceps tendon Supraspinatus tendon Infraspinatus tendon Subacromial subdeltoid bursa Notes: Plane/ region: Transverse (oblique axial): What you will see: Deltoid Greater tuberosity Articular cartilage Long head of the biceps tendon Supraspinatus tendon Infraspinatus tendon Subacromial subdeltoid bursa Infraspinatus and teres minor muscles and tendons Patient position: Anterior/ lateral to examiner Shoulder medial rotation Hand on opposite thigh Plane/ region: Transverse (oblique sagittal) – two locations: Over muscles; perpendicular to spine of scapula Over tendons; just lateral to acromion What you will see: Spine of scapula Deltoid Infraspinatus muscle and tendon (a more lateral position) Teres minor muscle and tendon Greater tuberosity Notes: Posterior glenohumeral structures Patient position: Anterior/ lateral to examiner Shoulder medial rotation Hand on opposite thigh Plane/ region: Longitudinal (axial) – 2 positions; 2nd more lateral What you will see: Spinoglenoid notch Bony glenoid Humeral head Infraspinatus and teres minor tendons (longitudinally) Posterior labrum Elbow Checklist Anterior Elbow Patient position: Facing the examiner Elbow in extension - over table Plane/ region: Transverse (axial): from 5cm above joint to the joint line What you will see: Biceps (superficial) Brachialis (deep; tendon forms laterally within muscle belly) Brachial artery (medial to biceps) Median nerve (medial to artery) Articular cartilage of trochlea and capitellum Pronator and brachioradialis muscles bounding the cubital fossa Notes: Note the decreasing size of biceps muscle and increasing thickness of the brachialis tendon as you slide distally. Distal Biceps and Brachialis Insertions Patient position: Facing the examiner Maximal supination Plane/ region: Longitudinal (sagittal) What you will see: Brachial artery Biceps tendon – passing in front supinator on the way to insertion Distal brachialis muscle and tendon Coronoid fossa Fat pads in radial and coronoid fossae Brachialis Capitellum and trochlea(articular cartilage) Radial head + annular ligament Supinator Notes: Biceps tendon curves distally and posteriorly. Apply pressure and tilt to get probe parallel to tendon Brachialis is; only a short tendon Lateral Patient position: Facing the examiner Full extension or 90 degrees flexion Palms together Thumbs up Plane/ region: Longitudinal (coronal) – proximal end at lateral epicondyle What you will see: Brachioradialis insertion Common extensor tendon (posterior to brachioradialis) Lateral synovial fringe Lateral epicondyle Radial head Plane/ region: Transverse (axial) What you will see: Common tendon origin Notes: Radiocapitellar Joint Patient position: Facing the examiner Full extension (transverse) or 90 degrees flexion (longitudinal) Plane/ region: Longitudinal (coronal) – proximal end at lateral epicondyle What you will see: Common extensor tendon Lateral synovial fringe Lateral epicondyle Radial head (note cartilage) Plane/ region: Transverse (axial) What you will see: Annular ligament Radial head (note cartilage) Radial shaft Supinator Notes: Dynamic scanning during passive pronation/ supination Medial Elbow Patient position: Facing the examiner Full extension and supination External rotation at shoulder and 90 degrees flexion at elbow (for medial collateral ligament) Plane/ region: Longitudinal (coronal) – proximal end at medial epicondyle What you will see: Common flexor tendon (thinner and shorter than extensor tendon) Medial epicondyle Ulna Anterior part of medial collateral ligament Notes: Dynamic scanning with valgus stress for medial collateral ligament Posterior Elbow – Triceps Patient position: Examiner standing behind patient Full (forced) pronation with 90 degrees flexion Plane/ region: Longitudinal (sagittal) proximal to olecranon and posterior to elbow and olecranon process What you will see: Olecranon Posterior olecranon recess (fluid more visible at 45 degrees) Fat pad in olecranon fossa Triceps muscle Triceps tendon Olecranon bursa Notes: Use only light pressure for olecranon bursa Cubital Tunnel and Ulnar Nerve Patient position: Examiner standing behind patient Full pronation with extension 90 degrees flexion at elbow Plane/ region: Transverse (axial); medial to olecranon and posterior to elbow What you will see: Olecranon process Medial epicondyle Cubital tunnel retinaculum Ulnar nerve (rotate probe to longitudinal once you see the nerve) Notes: Wrist/ Hand Checklist Dorsal Wrist: 1st Extensor Compartment Patient position: Sitting; mid-pronation with thumb up Plane/ region: Transverse (axial) anterior to radial styloid and 2cm proximal/ distal to it What you will see: Abductor pollicis longus Extensor pollicis brevis Radial artery Cephalic vein Notes: If having difficulties locating compartment, start by finding artery Dorsal Wrist: 2nd Extensor Compartment Patient position: Sitting; full pronation Plane/ region: Transverse (axial) over dorsal radius laterally and 2cm proximal to it What you will see: Extensor carpi radialis longus and brevis tendons; diverging distally More cranially, the tendons from the 1st compartment (abductor pollicis longus and extensor pollicis brevis) crossing ECRL and ECRB Notes: Use Lister’s tubercle as the medial landmark Dorsal Wrist: 3rd Extensor Compartment Patient position: Sitting; full pronation Plane/ region: Transverse (axial) over dorsal radius laterally What you will see: Extensor pollicis longus crossing the tendons from the 2nd compartment (more laterally the more distal) Extensor carpi radialis brevis and longus tendons Notes: Use Lister’s tubercle as a landmark in the middle of the screen Use the muscles from the 1st and 2nd compartments for reference Dorsal Wrist: 4th and 5th Extensor Compartment Patient position: Sitting; full pronation Plane/ region: Transverse (axial) over dorsal mid and medial radius What you will see: Extensor digitorum communis Extensor indicis proprius Extensor digiti minimi Articular cartilage of ulnar head Extensor pollicis longus cross the common extensor tendons a few cm proximally Notes: 4th compartment (extensor communicis) is distinct, hyperechoic 5th compartment (extensor digiti minimi ) is over the distal radioulnar joint Use Lister’s tubercle as a lateral landmark Scapholunate Ligament Patient position: Sitting; full pronation Hand in ulnar deviation Plane/ region: Oblique transverse (slightly lateral and distal) over dorsal lateral wrist. What you will see: Extensor digitorum communis Extensor digiti minimi Extensor carpi radialis brevis Notes: 4th compartment (extensor dig. communis) is superficial to lunate Add a longitudinal scan of scaphoid while doing ulnar and radial deviations Dorsal Wrist: 6th Extensor Compartment Patient position: Sitting; forearm extended back Hand in mid-pronation; ulnar side up Plane/ region: Transverse (axial) over distal/ dorsal ulna What you will see: Extensor carpi ulnaris tendon Styloid process of ulna Notes: Extend wrist to see extensor carpi ulnaris tendon lifts extensor retinaculum Distal Radioulnar Joint Patient position: Sitting; full pronation Plane/ region: Transverse (axial) over distal/ dorsal radius and ulna What you will see: Distal radioulnar joint line and recess 4th and 5th compartment tendons Ulnar head and neck Notes: Do short range pronations to identify joint relative to the stationary ulna Dorsal Radiocarpal and Mid-Carpal Joints Patient position: Sitting; full pronation and slight flexion Plane/ region: Longitudinal (sagittal) over a) Dorsal/ lateral radius to 1st metacarpal b) Dorsal/ medial radius to 3rd metacarpal c) Dorsal ulna to 5th metacarpal What you will see: All carpal bones except
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