essential features of musculoskeletal ultrasound · arm weakness, elbow pain complete distal biceps...

MSK Ultrasound: The Basics and

The Future

Kate G. Hartley, M.D.

Director, MSK Imaging Fellowship

Assistant Professor of Radiology and Emergency Medicine

Department of Radiology and Radiological Sciences

Vanderbilt University

Disclosures

• I have no commercial or financial interests to

disclose

Educational Objectives

1. Discuss the advantages and disadvantages of

ultrasound for evaluation of the MSK system

2. Identify the normal appearance of structures

commonly encountered in MSK imaging

3. See common pathologies that can be assessed

with US

4. Learn about current experimental MSK

applications of HIFU

Advantages • Low-cost (1)

• Patient friendly (2)

• Focused exams

• Dynamic, real time exams

• Excellent spatial resolution

– 150 microns v 450 microns (MRI)

– Even greater resolution with up to 70 MHz probes – 30microns

• Contralateral comparisons

• Portable

• No ionizing radiation or contrast 1.Jacobson JA. Ultrasound in sports medicine. Rad Clin NA 2002;40(2):363–86.

2. Middleton WD, Payne WT, Teefey SA, Hildebolt CF, Rubin DA, Yamaguchi K. Sonography and MRI of the shoulder: comparison

of patient satisfaction. AJR 2004;183(5):1449–52.

Disadvantages

• Operator dependant

– Good technique, transducer selection, setting, etc.

• Dependant on body habitus

– Advances in tissue harmonics have helped in these

challenging cases(5)

• Artifacts that mimic pathology

5. Rosenthal SJ, Jones PH, Wetzel LH. Phase inversion tissue harmonic sonographic imaging: a clinical utility study. AJR

2001;176:1393–8.

Anisotropy

• Property of all tendons

• Occurs when US beam not 90o

• Can simulate pathology

ULTRASOUND BEAM

PERPENDICULAR TO TENDON

ULTRASOUND BEAM

OBLIQUE TO TENDON

NORMAL ECHOGENICITY

OF BICEPS TENDON

ARTIFICIALLY LOW

ECHOGENICITY

Cases and Problem solving

Shoulder Pain Normal Anterior Tibial Tendon

Rotator Cuff Normal US appearance

• Homogeneous

echotexture

• Convex external

contour

• Smooth bony

margins GT

HH

Complete Tear of Supraspinatus Tendon

De Jesus et al, AJR 2009; 192:1701-1707

Partial Thickness Articular Sided Tear

Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Tech Assess 2003;7(iii):1–166.

Arm weakness, elbow pain

Arm weakness, elbow pain Complete Distal Biceps Tendon Rupture

Medial Elbow Pain

Common Flexor Tendons

Make the Diagnosis:

Tendinosis/Tendinopathy

• Thick, heterogeneous tendon

• Nodular, hypoechoic areas

• Calcification

• Interstitial splits

• Increased Doppler flow (variable)

Calcific Tendinosis, Subscapularis Lateral Epicondylosis

Intrasubstance tearing neovascularity

Medial Ankle Pain

Tibialis posterior longitudinal split tear

Partial Achilles Tendon Tear/Tendinosis

Joints Advantages

• More accurate, potentially more therapeutic joint

injections

– Blind knee joint injections may miss the joint in up to

29% of cases (3)

– Blind subacromial injections may miss 24-31% of the

time (4)

3. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. JBJS Am 2002;84A(9):1522–7. 4. Henkus HE, Cobben LP, Coerkamp EG, Nelissen RG, van Arkel ER. The accuracy of subacromial injections: a prospective randomized magnetic resonance imaging study. Arthroscopy 2006;22(3):277–82.

Aspiration of Shoulder Effusion

H

G

Elbow Effusion

Ulna

Hip Effusion

Head

Neck

Knee Effusion from OA

Where should I tap this joint? Ultrasound guides

successful aspiration

Bursae

• Common locations

– Subacromial, greater trochanteric, olecranon,

semimembranosus/medial gastrocnemius

• Compressible

• Thin, hypoechoic structures, <1-2 mm when not

distended.

Popliteal Mass

Chronic Olecranon Bursitis

Olecranon

Muscle

Normal Muscle

Long axis Short axis

Indirect trauma/ strain

Direct trauma

Destroyed fibers

Irregular intramuscular cavities

Hematomas

Nerves

Fascicular Pattern of Nerves

Transverse Longitudinal

Hand Tingling

Yesildag A, Kutluhan S, Sengul N. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal

tunnel syndrome. Clin Radiol 2004;59:910–5.

Carpal Tunnel Syndrome

Radial nerve

Screw tip abrading the nerve

Successful perineural injection

Ligaments Pitcher with medial elbow pain

Valgus Stress on Elbow

www.essr.org

Nazarian LN, et al . Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in symptomatic major league

baseball pitchers. Radiology 2003;227(1):149–54.

Ankle Sprain

F

T

Ankle Sprain

Bone

• Brightly echogenic line with acoustic shadowing

• Things that can be seen

– Unsuspected stress fractures

– Degenerative changes

– Erosions from rheumatic disease or osteomyelitis

Persistent Shoulder Pain

(6 months after MVA)

Unsuspected Humeral Impaction Fracture

Rib Fracture Missed on Plain Film

Non-tender Tender

Targeted problem solving

Child with foot pain and swelling Power Doppler of Foreign Body Reaction

Intraoperative tendon injury

index digit

Intraoperative tendon injury

long finger

The Future.

Surgery without knives

• “Focused ultrasound is an early-stage, non-

invasive therapeutic technology with the potential

to transform the treatment of many medical

disorders by using ultrasonic energy to target

tissue deep in the body without incisions or

radiation”

-Focused Ultrasound Foundation

The Technology

• High intensity focused ultrasound—provides the

energy to target and treat deep tissues in the body

precisely and noninvasively

• MRI -- used to identify and target the tissue to be

treated, guide and control the treatment in real

time, and confirm the effectiveness of the

treatment.

Focused Ultrasound Physics

http://www.medgadget.com/2012/10/exablate-mr-guided-focused-ultrasound-approved-in-u-s-for-pain-treatment-in-cancer-patients-with-bone-metastases.html

Focused Ultrasound Foundation Focused Ultrasound Foundation

Focused Ultrasound Foundation

Summary

• Ultrasound is robust tool, complimentary to MRI,

in the diagnosis of MSK pathology

• Relative low cost, portability, real-time imaging for

on the spot clinical decision making and the ability

to guide intervention are driving increasing

popularity

• While in its relative infancy, HIFU is capable of

becoming a revolutionary new, totally non-invasive,

radiation free, treatment option

essential features of musculoskeletal ultrasound · arm weakness, elbow pain complete distal biceps...

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