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A GUIDE to MUSCULOSKELETAL ULTRASOUND 1 a Guide to Musculoskeletal Ultrasound Examination Techniques and Ultrasonography of Normal Structures and Pathology

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A GUIDE to MUSCULOSKELETAL ULTRASOUND 1 a Guide to Musculoskeletal Ultrasound Examination Techniques and Ultrasonography of Normal Structures and Pathology A GUIDE TO MUSCULOSKELETAL ULTRASOUND 1 A Guide to Musculoskeletal Ultrasound Examination techniques and ultrasonography of normal structures and pathology Michel Court-Payen, MD, Ph.D. A GUIDE TO MUSCULOSKELETAL ULTRASOUND 2 TABLE OF CONTENTS EXAMINATION TECHNIQUE........................................................................................3 Choice of transducer.........................................................................................................3 Patient position. ...............................................................................................................4 Ultrasound examination...................................................................................................4 ULTRASONOGRAPHY OF NORMAL ANATOMICAL STRUCTURES........................5 Tendons, tendon sheaths and bursae...............................................................................5 Joints................................................................................................................................5 Muscles ............................................................................................................................6 Nerves...............................................................................................................................6 Bone..................................................................................................................................6 Fat.....................................................................................................................................6 Skin...................................................................................................................................7 PATHOLOGY....................................................................................................................7 Tendons, tendon sheaths and bursae...............................................................................7 Shoulder............................................................................................................................8 Knee..................................................................................................................................9 Ankle and foot.................................................................................................................10 Hip...................................................................................................................................11 Wrist and hand...............................................................................................................12 Elbow...............................................................................................................................12 Joint diseases.................................................................................................................13 Muscles...........................................................................................................................13 Nerves.............................................................................................................................14 Bones..............................................................................................................................14 CONCLUSION...............................................................................................................14 A GUIDE TO MUSCULOSKELETAL ULTRASOUND 3 MICHEL COURT-PAYEN, MD, PH.D. DEPARTMENT OF MUSCULOSKELETAL RADIOLOGY, GILDHØJ PRIVATE HOSPITAL, DENMARK Ultrasonography has become an invaluable first-line imaging modality for the diagnosis and treatment of dis- eases of the musculoskeletal system. Ultrasonography is an easy, quick and non-invasive technique, enabling constant interaction with the clinical examination. Technological advances have made it possible to obtain high-resolution dynamic images, which may even make ultrasonography a better alternative to magnetic res- onance imaging (MRI) in a great number of patients with soft tissue abnormalities. Ultrasonography is also the best modality for imaging guidance of interventional procedures. EXAMINATION TECHNIQUE An ultrasound examination of the musculoskeletal system does not require any preparation and has no contraindica- tions. It should follow some important rules regarding: 1. Choice of transducer 2. Patient position 3. Ultrasound examination Linear Array High frequency Linear Array 1. Choice of transducer 8811 (12- 5 MHz) 8870 (18 -6 MHz) A high frequency linear array is mandatory. The use of high frequencies (18-6 MHz) provides exquisite image resolu- Fig. 1. High frequency linear array transducers. tion (Fig. 1), often better than with MRI. Small transducers, formed like a hockey stick, are available and are best suited for examination of the superficial structures of the wrist/ hand or ankle/foot (Figs. 2). If a higher penetration is re- quested (obese or athletic patient, examination of menisci in the knee or anterior glenoid labrum in the shoulder), a lower frequency is preferable. A linear array provides a large field of view in the near-field zone, but cannot give the same overview that is available with computed tomography or MRI. The most important advantage of a linear array is that the ultrasound beams are all parallel, and can all be oriented at the same time perpen- Fig. 2a. Very high frequency linear Fig. 2b. Hockey Stick transducer dicular to the reflective structures of the soft tissues (e.g. array transducer, Hockey Stick 8809 equipped with needle guide. tendons and muscles), thus avoiding the anisotropic artifact transducer 8809, (15-6 MHz) for examination of very superficial (see sub section 3, “Ultrasound Examination”). structures (wrist/hand and ankle/foot). A GUIDE TO MUSCULOSKELETAL ULTRASOUND 4 2. Patient position Patient position depends on the examined region–supine for the quadriceps tendon, the patellar tendon or the anterior recess of the hip; prone for the popliteal fossa, for the Achilles tendon or the plantar fascia; seated for the rotator cuff of the shoulder (Fig. 3a). A small cuff can be placed under the knee or ankle to straighten the fibers of the extensor mechanism of the knee or the Achilles tendon. Internal rotation of the shoulder with the arm behind the back has same effect on the supraspinatus tendon. Fig. 3a. Ultrasound examination of the Fig. 3b. Corresponding normal transverse Fig. 3c. Transverse view of the bicipi- shoulder with the patient seated. view of the long head of the biceps in the tal groove in a patient with effusion in bicipital groove. the bicipital tendon sheath. 3. Ultrasound examination Perpendicular examination. One should always examine Color Doppler examination. Detection of soft tissue vessels most musculoskeletal structures (tendons, ligaments, muscles makes it possible to differentiate between solid tissue and and menisci) perpendicularly, to provide strong reflections and fluid, and to identify regions that may represent inflammation good visualization of the anatomical details. This is important (Fig. 6), tissue regeneration or tumors. to differentiate true pathology from the anisotropic artifact, Dynamic examination. Use scanning during active mobiliza- which appears when anatomical structures are examined with tion of the soft tissues whenever it may provide additional in- a certain angle and are falsely hypoechoic (Fig. 4). formation. This is also one of the strengths of ultrasonography. Comparison with the contralateral side. Examine the The physiological information thus obtained makes it easier to opposite limb as a reference if there is any doubt about the recognize anatomical structures and to situate the position, ex- ultrasound findings. The split-screen facility makes it easier tension and boundaries of pathological changes. Dynamic tests to compare subtle differences in size, form or echogenicity may help the visualization of small tendon or muscle tears, between both sides (Fig. 5). muscle hernias, tendon subluxation, glenoid labrum lesions, shoulder impingement and joint instability. Interaction with the clinical findings. One of the important advantages of ultrasonography is the direct interaction with Ultrasound-guided interventional procedures. Ultra- the clinical examination (symptoms and palpation findings). sonography provides “real-time” images and is ideal for the guidance of interventional procedures. When needed, they Sonopalpation. Compression with the transducer may provide should be an integral part of the ultrasound examination. Using information about the structure (fluid vs. solid) and elasticity a needle guide (Fig. 2b) or free-hand, the following diagnostic (malignant tumor or fibrosis vs. benign tumor or fat) of the soft and therapeutic procedures may be performed: tissues. Remember that the use of a large amount of gel and minimal pressure (or no contact between transducer and skin) • evacuation of fluid collections (abscess, hematoma, may be important to visualize very superficial soft structures, serma, bursitis, cyst and joint effusion) by puncture or as they may “disappear” when examined with too much com- catheter drainage pression (bursitis, tenosynovitis). A GUIDE TO MUSCULOSKELETAL ULTRASOUND 5 • needle biopsies (soft tissue tumor, enlarged lymph node, on the color Doppler examination. At bone insertions, metic- suspected recurrence in patients with operated sarco ulous examination perpendicular to the tendon fibers often ma). Steroid injection (joint, tendon sheath or bursa) reveals
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