Knee Ultrasound - moodle.kpsahs.edu
Transcript of Knee Ultrasound - moodle.kpsahs.edu
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KNEE ULTRASOUND
Vanessa McGowan, MD MS
August 8th, 2016
Kaiser Permanente
Physical Medicine and Rehabilitation
Musculoskeletal Medicine
Spine
South Sacramento
Thanks to Shawn Hsieh for slide assistance
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Indications
Include, but not limited to:
• Soft tissue injury
• Tendon and collateral ligament pathology
• Arthritis
• Soft tissue masses / swelling
• Loose intra-articular bodies
• Effusion
• Bone injury
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Knee Exam - ApproachComprehensive exam: includes 4
quadrants – exam tailored to clinical
presentation
4 quadrants: AnteriorMedialLateral
Posterior
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Anterior Knee
• Patient supine, knee slightly flexed ~30°
• Tenses extensor mechanism to reduce anisotropy
• Structures: quadriceps & patellar tendons,
patellar retinaculum, suprapatellar recess,
prepatellar / superficial & deep infrapatellar
bursae, distal femoral trochlear cartilage (max
flex), ACL insertion
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Quad Tendon Probe Technique
Quad tendon
Longitudinal / Sagittal / (Long Axis) Transverse / Axial /
(Short Axis)
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Normal Quad Tendon
Good view to screen for joint effusion
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Quad Tendinosis
• Hypoechoic thickening without disruption of fibers
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Quad Full-Thickness Tear
• Curved arrow – bone
avulsion
• Dynamic study – bone
moves away with knee
flexion
• Tendon may appear
wavy
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Suprapatellar Joint Recess: Effusion
• Arrows – quad tendon
• 1 – suprapatellar /quadriceps fat pad
• 2 – prefemoral fat pad
*suprapatellar
synovial
recess with
small
EFFUSION
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Pre-Patellar Bursitis
• A / B –
longitudinal
• C –
transverse
• Transducer is
floated
• Housemaid
or carpet
layer
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Patellar Tendon - Longitudinal view
• A small deep infrapatellar bursa is normal
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Patellar Tendon - Transverse view
• Good for seeing partial
tears or focal tendinosis
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What is the Dx?
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You turn on Doppler and see…
Increased flow –
hyperemia / increased
vascularity (not really
inflammation)
Dx: Patellar tendinosis
AKA Jumper’s knee
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Medial Knee
• Patient remains supine, slight flexion of knee
(~30°), hip with slight external rotation
OR
• Patient in lateral decubitus position, legs
scissored
• Structures: joint space, medial / tibial collateral
ligament, pes anserine tendons (sartorius,
gracilis, semitendinosus) / bursa, medial patellar
retinaculum, medial meniscus (valgus stress)
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Technique
Medial knee Lateral knee
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Normal Views
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Meniscus Tear
• Hypoechoic cleft
Posterior horn medial meniscus most common
tear location
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MCL
A – Technique
B – Arrows: superficial layer,
arrowheads: deep layer,
curved arrow: medial
meniscus
C – focus on this area for
tears…close to origin
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MCL Injury
Grade 1 Grade 3
Remote injury
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MCL / Pes
Anserine
D – MCL anisotropy
E – Insertion
arrowheads:
superficial MCL
(inserts 4-5 cm
below joint line),
arrows: pes
anserine tendons
superficial to MCL
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Lateral Knee
• Patient supine with ipsilateral hip internally
rotated
OR
• Patient in lateral decubitus position, pillow may be
placed between knees for comfort
• Structures (post to ant): popliteus tendon, biceps
femoris tendon, lateral / fibular collateral
ligament, iliotibial band / bursa, lateral patellar
retinaculum, lateral meniscus (varus stress)
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Coronal view technique
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Normal coronal views
B: ITB - anterior to joint line, ITB,
landing on Gerdy’s tubercle
C: LCL - Rotate distal transducer
posteriorly toward fibula to see
proximal LCL, with popliteus origin
deep to it. Sits in a sulcus that can be
useful landmark
* In this position, may get valgus knee
angulation, making LCL look wavy,
with anisotropy. Consider putting
support underneath, i.e. other leg
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LCL
Coronal oblique view
E: LCL, with popliteus origin
deep to it on femur, L – lat
meniscus, T – tibia, fibula on
right edge of screen
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Biceps Femoris:
Rotate superior
transducer
posteriorly…
G: Biceps femorisinserting on fibula (muscle more hypoechoic than ligament)
Bottom: move a little more posterior to see common fibular nerve
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Posterior Knee
• Patient prone, leg extended
• Consider dropping transducer frequency
• Structures: popliteal fossa, popliteal artery / vein,
semimembranosus, medial / lateral gastroc
muscles / tendons / bursae, sciatic / tibial / fibular
nerves, posterior meniscal horns, PCL,
intercondylar region and ACL
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Technique
Longitudinal / Sagittal / (Long Axis) Transverse / Axial /
(Short Axis)
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Posterior Calf
Medial gastroc, Lat gastroc
and Soleus
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Medial popliteal fossa,
transverse view
Right = lateral, F – femur,
black arrow –
semitendinosus, open
arrow –
semimembranosus,
arrowheads – med
gastroc, tendon is curved
arrow. Center of picture –
look for BAKER’S CYST
here
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Transverse view
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Postero-medial Knee: Baker’s Cyst AKA semimembranosus –
medial gastroc bursa
Transverse on left, longitudinal on right. Open arrow –
communication to knee joint via sub-gastrocnemius (SG)
bursa (50% communicate to joint), black arrow – SM tendon
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Longitudinal View
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Postero-medial Knee: Baker’s Cyst AKA semimembranosus –
medial gastroc bursa
Transverse on left, longitudinal on right. Open arrow –
communication to knee joint via sub-gastrocnemius (SG)
bursa (50% communicate to joint), black arrow – SM tendon