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: