dynamic ultrasound findings - cs.oma.org · objectives at the end of this presentation, the...

Dynamic Ultrasound

Findings

Linda Probyn, MD, FRCPC

MSK Radiologist

No Disclosures

Objectives

At the end of this presentation, the participant

will be able to:

1. Describe relevant anatomy and US

appearances of joints and soft tissue

structures

2. Improve knowledge of common

pathologies, pitfalls and artifacts

3. Describe dynamic US findings that aid in

diagnosis

Structure

• Tendons

– Echogenic and fibrillar

– Uniform thickness

– Synovial sheath – thin

echogenic line around

tendon

– Small amount of fluid

normal

Retinaculum

• Retinaculum

• Normal structures

Tenosynovitis

• Distention of tendon

sheath with fluid or

synovial

hypertrophy

• Possible hyperemia

Synovitis

• Synovitis vs Fluid

– Fluid –

• anoechoic and

compressible

– Synovitis –

• Thick, hypoechoic,

edematous synovium

• non-compressible +/-

hyperemia on Doppler

flow

Fessell DP, Jacobson JA,

et. al. AJR 2000

Doppler

• Importance of using

Doppler or Power US

• Case: ? Muscle tear

Pseudoaneurysm

Pitfalls

• Anisotropy

– Beam reflected

away from

transducer if probe

not perpendicular

to the structure

– Appears

hypoechoic

Reflector

appears bright

Reflector

appears dark

Transducer

Transducer

Pitfall - Anisotropy

• Solution

– Heel toe transducer in

longitudinal

– Rock transducer in

transverse

Shoulder

Biceps

• Long head of biceps

– Located in bicipital groove

– Can sublux or dislocate

Biceps

• Long head of biceps

– Externally & Internally rotate to assess for

subluxation

Supraspinatus Impingement

• Supraspinatus can impinge under

acromion

• Abduct shoulder actively to 45 deg

Biceps brachii: Anatomy

• Insertion: Radial

tuberosity

• Blends with aponeurosis

• No synovial sheath

Biceps brachii tendon: Transverse

A

Brachialis

Trochlea

Medial Lateral

Median n. Radial n.

Short axis

Biceps tendon

Biceps brachii tendon: Long

Long axis

Radial

Tuberosity

Distal Proximal

Medial approach

Biceps brachii tendon: Lateral

Distal Proximal

Radial

head

Supinator

Kalume Brigido M. Eur Radiol 2009

Biceps brachii tendon: Lateral

Kalume Brigido M. Eur Radiol 2009

Supination

Pronation

R E

E

S

Distal Proximal

Radial

head

Ulnar nerve

Ulnar nerve

ME O

Ulnar groove

Long axis

Short axis

T

Ulnar nerve – Dynamic Assessment

Snapping Ulnar Nerve & medial

head of triceps • Ulnar nerve

dislocates over

medial epicondyle

with flex/ext of elbow

• Medial head of

triceps can also

dislocate

• May have double

snap

Medial Elbow Jacobson JA, Jebson PJ, et. al. Ulnar nerve dislocation and

snapping triceps syndrome: diagnosis with dynamic sonography –

report of three cases. Radiology 2001;220(3):601-5.

Extensor tendons

• 6 Extensor compartments

1

2

3 4 5

6

Extensor pollicis

brevis EPB

Abductor pollicis

longus APL

Extensor carpi radialis

brevis ECRB

Extensor carpi radialis

longus ECRL

Extensor pollicis

longus EPL

Extensor digitorum ED

Extensor indicis EI

Extensor digiti minimi EDM

Extensor carpi

ulnaris ECU

Lister’s

tubercle

Radius Ulna

Extensor tendons

1

2

3 4 5

6

Radius Ulna

Lister’s

tubercle

Extensor tendons

• Compartment 1 – crosses over 2


www.exercisebasics.net

Intersection Syndrome (distal)


www.exercisebasics.net

Guyon’s Canal

P

P

FCU

FCU • Semi-rigid canal

• Medial – pisiform,

FCU

• Superficial – palmar

carpal ligament

• Deep – flexor

retinaculum

• Passage of ulnar

artery and nerve

Guyon’s Canal

www.emedmd.com

www.capefearcyclists.org

P

P

FCU

FCU

Guyon’s Canal

P

P

FCU

FCU

Screw Impingement

• Metalwork can

impinge upon

nerves and tendons

• Dynamic

assessment helpful

Anatomy

Transverse Head

Oblique Head

Adductor Pollicis

Extensor Pollicis

Longus Tendon

UCL

Adductor

apponeurosi

s radial n.

www.eorthopod.co

m

www.winkingskull.com

www2.aofoundation.org

• Avulsion of UCL at MCP

joint (usually distal)

• May see # fragment

(usually base of phalanx)

• May be isolated ligament

injury

• Skier’s thumb – acute

• Gamekeeper’s – chronic

Tear UCL

Ligament Avulsion

Fracture

Skier’s Thumb

http://www.houstonmet

hodist.org/orthopedics

Skier’s Thumb

www.foundrysportsmedicine.com

Stener Lesion

• UCL ligament

stump displaced

• Lies superficial

to adductor

aponeurosis

Acute Skier’s Thumb Repaired With a Proximal Phalanx Suture

Anchor. C Zeman et. al. Am J Sports Med. 1998;26(5):644-650

UCL

Metacarpal Proximal

Phalynx

Metacarpal Proximal

Phalynx

UCL

Metacarpal Proximal

Phalynx

UCL – Adductor apponeurosis

Metacarpal Proximal

Phalynx

UCL – Adductor apponeurosis

• Location of the

adductor

aponeurosis

explains why a

displaced UCL

tear does not

reduce (Stener

lesion)

Pulley Anatomy

• Fibrous expansion of

flexor tendon sheath

• Function as fulcrum

• Assist finger flexion

http://radsource.us

Pulley system From Neumann DA. Kinesiology of the Musculoskeletal

System. St. Louis: Mosby, 2002

www.theyclimb.com

• A2 and A4 pulleys most

important for function

• Most common in rock

climbers

• A2 pulley

• Hyperextension DIP with

PIP flexion

Pulley system http://radsource.us

Proximal phalanx

A2 Pulley

Pulley Injury

Normal

A2 Pulley Injury

Courtesy Dr. Mark Cresswell

Trigger Finger

• Mostly at MCP A1

pulley

• US

– Thickening of pulley

– Associated cystic lesion

– +/- tendinopathy (50%)

Snapping Iliopsoas Tendon

• Cause of external

snapping hip

• Portion of the tendon

moves abruptly over

iliopectoneal

eminence


• Portion of tendon

transiently trapped

during flexion,

external rotation and

abduction of the hip

• Other causes:

– Bifid tendon moving

around itself

– Snapping over

paralabral cyst

Case courtesy of Dr Matt Skalski,

Radiopaedia.org, rID: 45907



transiently trapped

during flexion,



• Other causes:


around itself

– Snapping over

paralabral cyst

Lin Y, Want T. Ultrasonopraphic Examination of the Adult Hip. J

of Medical Ultrasound. Dec 2012 20(4), pages 201-209.



transiently trapped

during flexion,



• Other causes:


around itself

– Snapping over

paralabral cyst

Peroneal Tendons

• Peroneus Brevis

• Peroneus Longus

Fibula

Tendon Subluxation

• Peroneal Tendons

– Tendons more

anterior and lateral

than normal

– Elicited with

dorsiflexion &

eversion

Achilles & Plantaris Tendon

Plantaris

• Origin: lateral

supracondylar ridge of

femur above lat.

Gastrocs

• Insertion: Medial

Achilles tendon at

calcaneus

• Can mistake for intact

Achilles tendon https://www.pinterest.ca/Effiekusuma/muscle/?lp=true

Achilles Tear & Intact Plantaris

Long

Calcaneus

Trans

Trans

Achilles Tear & Intact Plantaris

Long

Treatment

• Nonoperative vs.

Operative

• Level 1 evidence: no

difference in re-

rupture rates with

functional

rehabilitation

Soroceanu A, Sidhwa F, et. al. Surgical vs nonsurgical

Treatment of Acute Achilles Tendon Rupture A meta-

analysis of randomized trials. JBJS 2012;94:2136-43.

• <1 cm: non-operative (maybe

elite athlete)

• 1-2.5 cm: non-operative older

pt. & offer choice for active pt.

• >2.5 cm: surgery

The End

Linda Probyn, MD FRCPC

[email protected]

mailto:[email protected]

References

Chiavaras MM, Jacobson JA, Yablon CM, Kalume Brigido M, Girish G.

Pitfalls in Wrist and Hand Ultrasound. AJR:203, September 2014

Lee JC, Healy JC. Normal Sonographic Anatomy of the Wrist and Hand.

Radiographics 2005; 25:1577-1590

Khoury V. et al. Semin Musculoskelet Radiol 2007: Ultrasound of Ankle and

Foot: Overuse and Sports

Dong Q, Fessell D. Achilles Tendon Ultrasound: AJR 2009;193:w173

Ebrahim FS, De Maeseneer M, Jager T, et. al. US Diagnosis of UCL Tears

of the Thumb and Stener Lesions: Technique Pattern-based Approach, and

Differential Diagnosis. Radiographics 2006; 26:1007-1020.

dynamic ultrasound findings - cs.oma.org · objectives at the end of this presentation, the...

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