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 pisiform  Distal radius and ulna  Tendons of all dorsal compartments

Notes:  Do short range extension to identify joint lines against stationary radius/ ulna

Proximal Carpal Tunnel Patient position:  Sitting; full supination

Plane/ region: Transverse (axial) over proximal row of carpal bones.

What you will see:  Carpal bones, particularly proximal row  Flexor digitorum tendons  Flexor carpi radialis tendon  Flexor retinaculum  Flexor pollicis longus tendon  Ulnar nerve and artery in Guyon tunnel.  Median nerve

Notes:  Keep pisiform and tubercle of scaphoid in view as fixed points  Tilt probe and flex fingers

Distal Carpal Tunnel Patient position:  Sitting; full supination

Plane/ region: Transverse (axial) over proximal row of carpal bones.

What you will see:  Carpal bones, particularly distal row  Flexor digitorum tendons  Flexor carpi radialis tendon  Flexor retinaculum  Flexor pollicis longus tendon  Ulnar artery  Ulnar nerve now split into superficial (medial) and deep  Median nerve

Notes:  Keep ridge of trapezium and hook of hamate in view as fixed points  Tilt probe and flex fingers

Hip Checklist

Anterior Hip: Joint Recess and Iliopsoas Tendon Patient position:  Supine

Plane/ region: Oblique longitudinal (sagittal) over femoral neck and hip joint  Over femoral neck  Over joint

What you will see:  Acetabulum  Anterosuperior labrum  Anterior joint recess  Femoral head  Femoral neck  Iliopsoas muscle  Iliopsoas tendon  Acetabular labrum

Plane/ region: Transverse (axial) over joint

What you will see:  Femoral head  Iliopsoas muscle  Iliopsoas tendon, in the deep, medial part of the muscle (over iliopectineal line)

Notes:

Rectus Femoris and Anterior Thigh Muscles Patient position: Supine

Plane/ region: Longitudinal (sagittal)

What you will see:  AIIS, directly above the head of femur  Direct tendon of rectus femoris  Indirect (reflected) tendon of rectus femoris

Plane/ region: Transverse (axial), from the level AIIS to 10cm distal to AIIS

What you will see:  AIIS  Direct tendon of the rectus femoris muscle  Iliopsoas muscle  Sartorius muscle  Tensor fasciae latae  Vastus intermedius muscle  Proximal myotendinous junction of rectus femoris  Rectus femoris muscle

Notes:

Lateral Hip: Gluteus Minimus, Medius, and Fascia Lata Patient position: Sidelying

Plane/ region: Transverse (axial) above greater trochanter from TFL anteriorly to gluteus maximus posteriorly

What you will see:  Gluteus maximus muscle  Gluteus minimus tendon and muscle  Gluteus medius tendon and muscle  Greater trochanter  Fascia lata

Plane/ region: Longitudinal (coronal plane)

What you will see:  Ilium  Gluteus maximus muscle  Gluteus minimus tendon and muscle  Gluteus medius tendon and muscle  Greater trochanter  Fascia lata Knee Checklist

Quadriceps Tendon

Patient position:  Supine with knee slightly flexed

Plane/ region: Longitudinal (sagittal) immediately above patella

What you will see:  Patella  Quadriceps tendon: o superficial layer (from rectus femoris) o intermediate layer (from vastus lateralis and medialis) o deep layer (from vastus intermedius) o Identify layers by moving obl/ laterally from vastus medialis muscle  Femur

Plane/ region: Transverse (axial) 5-10cm above patella

What you will see:  Vastus lateralis muscle  Vastus medialis muscle  Vastus intermedius muscle  Quadriceps tendon

Notes:

Femoral Trochlea

Patient position:  Supine with knee fully flexed

Plane/ region: transverse to tendon (axial) immediately above patella

What you will see:  Trochlea of femur  Articular cartilage of trochlea  Quadriceps tendon

Notes:

Patellar Ligament

Patient position:  Supine with knee slightly flexed

Plane/ region: Longitudinal (sagittal) immediately below patella, down to the tibial insertion

What you will see:  Patella  Patellar ligament  Superficial infrapatellar bursa  Deep infrapatellar bursa (between tendon and tibial epiphysis)  Fat pad of Hoffa  Tibia

Notes:

Medial Collateral Ligament and Pes Anserinus

Patient position:  Supine with knee slightly flexed; leg laterally rotated

Plane/ region: Longitudinal (coronal) below the medial epicondyle (more oblique anteriorly for pes anserinus)

What you will see:  Medial collateral ligament o superficial part o deep part  Medial meniscus  Pes anserinus insertion

Notes:  Scanning ligament while applying valgus stress may aid diagnosis

Iliotibial Band Patient position:  Supine with knee slightly flexed; leg medially rotated

Plane/ region: Longitudinal (coronal) from the lateral femoral condyle to Gerdy’s tubercle

What you will see:  Iliotibial band; asterisk, Gerdy’s tubercle; LFC,  Lateral femoral condyle

Plane/ region: Transverse (axial) medial and lateral to patella

What you will see:  Lateral/ medial parapatellar recesses  Lateral/ medial patellar retinacula  Femur  Patella

Notes:

Lateral Collateral Ligament

Patient position:  Supine with knee slightly flexed; leg medially rotated

Plane/ region: Longitudinal (oblique coronal – caudal/ posterior) above fibular head

What you will see:  Femur  Popliteal tendon  Lateral collateral ligament  Lateral meniscus  Fibular head

Notes:

Posterolateral Knee - Biceps Femoris

Patient position:  Prone with knee extended and laterally rotated

Plane/ region: Longitudinal (sagittal) immediately above joint line

What you will see:  Biceps femoris tendon  Articular cartilage of lateral femoral condyle  Biceps femoris muscle  Lateral meniscus  Fibular head  Lateral femoral condyle  Fabella (in 15-20%)

Notes:

Ankle Checklist

Anterior talofibular ligament

Patient position:  Seated on table; knee flexed to 45⁰, foot supported and inverted  Alternatively, sidelying with pillow under the medial malleolus

Plane/ region: Longitudinal (axial oblique; slightly caudal and anterior), at joint line

What you will see:  Lateral malleolus  Talus  Anterior talofibular ligament

Notes:  May do sonographic anterior drawer test: Patient prone with the foot over the edge of table while pulling the foot anteriorly in plantar flexion and inversion.

Anterior tibiofibular ligament

Patient position:  Seated on table; knee flexed to 45⁰, foot supported and inverted  Alternatively, sidelying with pillow under the medial malleolus

Plane/ region: Longitudinal to tibiofibular ligament (axial oblique; slightly caudal and lateral), at joint line

What you will see:  Lateral malleolus  Tibia  Anterior tibiofibular ligament

Notes:

Peroneal tendons

Patient position:  Sidelying with support under medial side of foot

Plane/ region: Transverse (axial oblique, across tendons), above joint line to 5th metatarsal base

What you will see:  Superior retinaculum (from fibula to Achilles tendon)  Inferior peroneal retinaculum (from fibula to calcaneus)  Peroneus brevis muscle and tendon  Peroneus longus muscle and tendon  Lateral malleolus  Calcaneus - peroneal tubercle  Cuboid  5th metatarsal base  Calcaneofibular ligament?

Notes:  Maintain probe perpendicular to tendons  When subluxation is suspected, add resisted dorsiflexion and eversion

Tibialis posterior and flexor digitorum longus tendons

Patient position:  Sitting or supine with support under lateral side of foot

Plane/ region: Transverse (oblique axial, across tendons), behind medial malleolus

What you will see:  Posterior tibial artery (between veins)  Medial malleolus  Posterior tibial veins  Tibialis posterior tendon  Flexor digitorum longus tendon  Flexor retinaculum  Talus  Naviculum

Notes:  Check for accessory os trigonum

Deltoid ligament

Patient position:  Sitting or supine with support under lateral side of the dorsiflexed foot

Plane/ region: Longitudinal (oblique coronal planes posteriorly and anteriorly tilted), below medial malleolus

What you will see:  Medial malleolus  Talus  Calcaneus  Tibials posterior tendon  Tibiotalar ligament  Tibiocalcaneal ligament

Notes:

Achilles tendon Patient position:  Prone with dorsiflexed foot over the edge of the table

Plane/ region: Longitudinal (sagittal plane) from the myotendinous junction down to the insertion of the tendon into calcaneus

What you will see:  Tibia  Calcaneus  Gastrocnemius  Soleus  Achilles tendon  Kager fat pad  Flexor hallucic longus muscle

Notes: