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Thigh Knee SINGAPORE NOTES Thigh and Knee Ultrasound Stephen Bird Quadriceps Insertion Quadriceps Insertion 3 Layers • Superficial: (Rectus Femoris) • Middle: (Vastus Medialis / Vastus Lateralis) • Deep: (Vastus Intermedius) • Partial tears commonly involve superficial layer only • Axial scans required to independently assess VM and VL involvement Quadriceps Tendon Layers Rectus Femoris Anatomy Rectus Femoris Anatomy Rectus Femoris Central Tendon Rupture Rectus Femoris Central Tendon Rupture Rectus Femoris Central Tendon Rupture Hamstring Ultrasound Stephen Bird Hamstring Origin : Enthesis / Tendon Belly : MTJ x 2 / Myo-fascial Boundary Insertion : Enthesis / Tendon Bursae : Ischial, Semimemb, Pes Anserine Adjacent Structures : Sciatic Nerve , Sacrotuberous Lig Hamstring Muscle and Tendon Units Ischial Tub ST BF Medial L/H Lateral SM BF S/H Knee Hamstring Muscle and Tendon Units Ischial Tub ST BF Medial L/H Lateral SM BF S/H SN Knee Hamstring Navigation Rules • In the standard Bakers cyst plane the Semitendinosus tendon lies stacked on top of the Semimembranosus tendon • The distal Semimembranosus tendon is short while the proximal tendon is long • The distal Semitendinosus tendon is long while the proximal tendon is short • Semitendinosus has the “inscription” Hamstring Navigation Rules • Sciatic Nerve always sits deep to the long head of Biceps Femoris • In the proximal hamstring the Semimembranous tendon (pseudo-sciatic nerve) always sits deep to the Semitendinous muscle belly • In the distal hamstring the Long Head of Biceps Femoris tendon sits superficial to the short head muscle • Adductor Magnus forms the floor Hamstring Navigation Rules • The first muscle to form as you head distal from the iscial tuberosity is semitendinosus • The biceps femoris long head and semitendinosus unite proximally to form the conjoint tendon • The conjoint tendon occupies the medial 2/3 of the ischial tuberosity • The proximal semimembranosus tendon occupies the lateral 1/3 of the iscial tuberosity • The common peroneal nerve sits against the medial edge of the short head of biceps femoris Origins What do we see Sonographically ? At the Ischial Tuberosity Note : C.T. = Conjoint Tendon (Semitend and Biceps Fem Long Head) Medial Lateral C.T. BF ST S.M. SN What do we see Sonographically ? 1cm Below the Ischial Tuberosity Medial C.T. Lateral S.M. SN What do we see Sonographically ? 2cm Below the Ischial Tuberosity Lateral Medial ST C.T. S.M. SN What do we see Sonographically ? 3cm Below the Ischial Tuberosity ST BF Medial (L/H) Lateral SM SN Common MTJ Injury Site What do we see Sonographically ? 3cm Below the Ischial Tuberosity Medial ST BF (L/H) Lateral SM SN Common MTJ Injury Site What do we see Sonographically ? • 1/3 of the way from Ischial Tuberosity to Knee BF Medial ST Lateral (L/H) SM SN Adductor Magnus What do we see Sonographically ? • 2/3 of the way from Ischial Tuberosity to Knee ST Medial BF Lateral (L/H) SM BF (S/H) SN What do we see Sonographically ? • Just above the Knee ST BF (L/H) Medial BF Lateral (S/H) SM What do we see Sonographically ? • At the Knee ST Medial Lateral BF SM Hamstring Origin Pathology • Tendinosis • Enthesopathy • Avulsion with preservation of the sacrotub ligament • Complete avulsion with rupture of sacroptub ligament • Proximal MTJ tear • Proximal central tendon rupture • Piriformis / Lateral Rotators • Sciatic Nerve • Ischial Bursa • Sacrotuberous Ligament Myofacial Vs MTJ Vs Central Tendon The MTJ Hot Spot Cohens Triangle Insertions G T S Pes Anserine Sartorius Gracilis Semitendinosus Pes Anserine Navigation Rules • Follow the MCL to its distal insertion (6-7cm below medial joint line) • Observe the 3 small tendons passing superficial to the MCL in short axis • Rotate almost 90 degrees with the posterior end of the transducer a little proximal relative to the distal end • Locate one of the tendons in LAX Pes Anserine Navigation Rules • Scan inferiorly until the tendons disappear • Slowly scan proximally identifying the 3 tendons individually • The order from proximal to distal is ST, Gr, Sart • The Pes Anserine bursa lies between the 3 tendons and the underlying MCL Biceps Femoris Insertion Intimate with FCL Semimembranosus Insertion Semimembranosus Insertion Knee Stephen Bird : © 2014 Knee Pathology, Joint Effusion / Synovial Hypertrophy 80% of patients with effusions >10mm have internal derangement. 14% of patients with effusions <10mm had derangement. Haemarthrosis Stephen Bird : © 2014 Synovitis Trochlear Cartilage Patellar Tendon Usual Tendinosis Distribution Patellar Tendinosis Patellar Tendon Vessel Ingrowth Hoffa’s Fat Pad Inflammation MCL 3 Layers •Superficial Layer Deep Fascia •Middle Layer Tibial Collateral Lig •Deep Layer Capsular Lig MCL Tear Pellegrini Stieda Meniscus Stephen Bird : © 2014 FCL Anatomy Bakers Cyst Anatomy Stephen Bird : © 2014 Bakers Cyst Anatomy Stephen Bird : © 2014 Bakers Cyst Stephen Bird : © 2014 Bakers Cyst Haemarthrosis Stephen Bird : © 2014 Ilio-Tibial Band Iliotibial Band Friction Syndrome Iliotibial Band Friction Syndrome Happy Scanning [email protected].
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