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 10.