Imaging of Snaps, Clicks, Disclosures: and Clunks • Consultant: BioClinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier • Not relevant to this talk Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.
Dynamic Imaging: Biceps Brachii Tendon:
• Shoulder • Subluxation: • Elbow – Partially perched on lesser tuberosity • Wrist and Hand • Dislocation: • Hip and Thigh – Empty bicipital groove • Knee – Simulates biceps tendon tear • Ankle and Foot – Associated subscapularis tears • Soft Tissues Farin et al. Radiology 1995; 195:845
Biceps Tendon Biceps Tendon Dislocation
* * Lesser Lesser Tuberosity Tuberosity
Subluxation Dislocation
1 Biceps Tendon Dislocation Impingement Syndrome • Cuff impingement • Subacromial enthesophyte or acromioclavicular joint osteophyte
• Associated tendon Supraspinatus degeneration and tear
Subacromial Impingement: anterior Subacromial Impingement • Thickened tendon or bursa – Possible snapping of thickened bursa – “Gathering” of bursa: may be asymptomatic1 • Superior movement of humeral head – Possible contact between humerus and acromion2
1Daghir A et al. Skeletal Radiol 2012; 41:1047 2Bureau N et al. AJR 2006; 187:216
Impingement: supraspinatus Dynamic Imaging:
• Shoulder • Elbow • Wrist and Hand • Hip and Thigh • Knee • Ankle and Foot • Soft Tissues
2 Technique: ulnar nerve subluxation
Ulnar Nerve Dislocation • Occurs in elbow flexion • Reduces in extension • Nerve irritation, predisposes to injury • Found in 20% asymptomatic volunteers E E O T
Okamoto, J Hand Surg 2000; 25B:85
Transverse
Isolated Ulnar Nerve Dislocation Snapping Triceps Syndrome Ulnar Nerve • Ulnar nerve and medial triceps dislocate
Medial over apex of medial epicondyle Epicondyle • Ulnar nerve and medial triceps remain in Apex contact with each other • Palpable snap felt through transducer
Short Axis Radiology 2001; 220:601
Snapping Triceps Syndrome: dynamic imaging Dynamic Imaging:
• Shoulder Anterior Posterior • Elbow • Wrist and Hand • Hip and Thigh • Knee • Ankle and Foot • Soft Tissues Transverse
3 Dislocation: extensor carpi ulnaris Extensor Carpi Ulnaris: • 6th extensor wrist compartment • Asymptomatic subluxation – Supination – Up to 50% out of groove – No tear or tenosynovitis
Lee KS et al. AJR 2009; 193:651 Short Axis
Trigger Finger: A1 pulley Trigger Finger: • Stenosing tenosynovitis: A1 pulley • Thick and hypoechoic pulley
• Hyperemia: 91% PP
• Tendinosis: 48% MC MC PP • Tenosynovitis: 55% Case #1 Case #2 Guerini et al. J Ultrasound Med 2008; 27:1407
Trigger Finger: thumb Dynamic Imaging:
• Shoulder • Elbow • Wrist and Hand • Hip and Thigh • Knee Case #1 Case #2 • Ankle and Foot • Soft Tissues
4 Iliopsoas Complex Snapping Hip Syndrome • Painful snap with hip motion • Intraarticular AIIS • Extraarticular:
– Anterior: iliopsoas tendon Ilium – Lateral: iliotibial tract or gluteus maximus
Red: psoas major Orange: medial iliacus fibers Purple: lateral iliacus fibers From: Guillin R. et al. Eur Rad 2009; 19:995
Snapping Hip Syndrome: iliopsoas Snapping Hip Syndrome: iliopsoas
• Long axis to inguinal ligament superior to femoral head • Extension of flexed abducted and externally rotated hip • Abrupt movement of iliopsoas as iliacus muscle interposed between tendon and bone moves Deslandes et al. AJR 2008; 190:576
Snapping Gluteus Maximus / Iliotibial Band
Gluteus Iliotibial Band Snapping Hip: lateral Medius TFL Gluteus Maximus Gluteus Maximus • Transverse over Gmin greater trochanter • Hip external rotation / flexion • Abrupt motion of iliotibial tract or gluteus maximus over greater trochanter
5 Intra-articular Body Dynamic Imaging:
• Shoulder P • Elbow Q • Wrist and Hand • Hip and Thigh
• Knee F F • Ankle and Foot Sagittal Axial • Soft Tissues
Intra-articular Body Nodular Synovitis: Snapping
T2w
Femur
Post-IV gadolinium
Patellar Clunk Syndrome
Patellar Clunk Syndrome: • After total knee arthroplasty • 1% to 7.5% incidence • Fibrous nodule: intercondylar notch • Pain with flexion - extension
Okamoto T. et al. J Orthop Sci 2002; 7:590
6 : Sartorius Snapping over Pes Anerinus Bursa Semitendinosus Snapping over Semimembranosus
Sartorius Semitendinosus
MG Bursa
Semimembranosus Tibia Tibia
Semitendinosus Snapping over Semimembranosus Dynamic Imaging: Semitendinosus • Shoulder • Elbow • Wrist and Hand • Hip and Thigh
Semimembranosus • Knee • Ankle and Foot • Soft Tissues
Peroneal Retinaculum
Peroneal Tendon: dislocation
• Implies retinaculum injury • Associated with tendon tear • Examine with dorsiflexion and eversion • Lateral subluxation / dislocation
Rosenberg et al. AJR 2003; 181:1551
7 Dislocation: peroneus brevis & longus Intrasheath Peroneal Subluxation
• Abnormal snapping of peroneal tendons Anterior Posterior • No lateral displacement, intact retinaculum • Associations: – Convex posterior fibula in 92% – Tendon tear in 86% – Low lying peroneus brevis muscle in 71%
J Bone Joint Surg Am 2008; 90:992 J Foot Ankle Surg 2009; 48:323 Short axis
Intrasheath Peroneal Subluxation: Type A Intrasheath Peroneal Subluxation
• Type A: – Peroneal tendon switch position within sheath – No coexisting peroneal tendon tear • Type B: – Subluxation of peroneus longus tendon into longitudinal split of peroneus brevis tendon
J Bone Joint Surg Am 2008; 90:992 Short Axis
Morton Neuroma: Technique: • Interdigital nerve entrapment • Interdigital space • Edema, fibrosis, necrosis – Transducer: rd nd • 3 intermetatarsal space > 2 • Plantar • Sharp, burning pain from • Dorsal metatarsal head to toes – Normal digital nerve • Females: pliable foot, high-heeled difficult to visualize narrow-toed shoes From: Martinoli, RadioGraphics – Correlate with symptoms 2000; 20:S199
8 Morton Neuroma Dynamic Evaluation • Compression • Hypoechoic 5 mm mass – Between transducer and – Sensitivity: 100% ; Specificity: 83% palpation – Accuracy equal to MRI – Bursae (dorsal) compress, – Nerve continuity: sagittal plane neuromas (plantar) do not • Intermetatarsal bursa • Sonographic Mulder Sign – Scan plantar: coronal plane – Associated with neuroma – Neuroma displaces: plantar – “Neuroma-bursal complex” – Palpable click Quinn T et al. AJR 2000; 174:1723 Bignotti B et al. Eur Radiol 2015; 25:2254 Torriani M et al. AJR 2003; 180:1121 Cohen SL et al. J Ultrasound Med 2016; 25:3191 Zanetti M et al. Radiology 1997; 203:516
Dynamic imaging: Mulder’s Maneuver Dynamic Imaging:
• Shoulder • Elbow • Wrist and Hand • Hip and Thigh • Knee • Ankle and Foot • Soft Tissues
Slipping Rib Syndrome Slipping Rib Syndrome • Abnormal mobility of cartilaginous rib • Slips over adjacent rib with muscle contraction or activity • Visible with dynamic ultrasound
J Ultrasound Med 2002; 21:339
9 Dynamic Imaging: summary • Dynamic pathologic conditions – Limited number – Involve specific structures • Consider ultrasound for any snapping or painful dynamic situation Syllabus on line and other educational material: www.jacobsonmskus.com Twitter handle: @jjacobsn
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