Uvod v MSK ultrazvok - Randy Moore
-
Upload
mideas-mitja-dobovicnik -
Category
Documents
-
view
218 -
download
0
Transcript of Uvod v MSK ultrazvok - Randy Moore
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 1/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore 1
Introduction to
MusculoskeletalUltrasound Imaging
Randy E. Moore, DC RDMS - www.mskmasters.com
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 2/34
Musculoskeletal sonography is well on its way tobeing accepted as “standard of care” in physical
medicine.
In the past few years, the most prominent
interest in this imaging modality has shifted from a need to visualize the “current physiologic
state” of the tissue, to accurate placement of
medication, and needle visualization.
The pre-requisite to identifying pathology, and
using ultrasound for injection guidance is todevelop the skill to accurately and eciently
identify normal musculoskeletal anatomy during
ultrasound examination.
Randy E. Moore, DC, RDMS
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 3/34
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 4/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore3
Table of Contents
Chapter 1 - Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapter 2 - Guidelines for Musculoskeletal Sonography . . . . . . . . . . . . . . . . 7
Chapter 3 - Basic Normal Musculoskeletal Ultrasound Anatomy . . . . . . . .11
Chapter 4 - The Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Biceps Tendon Short Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Biceps Tendon Long Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anterior Rotator Cu: Supraspinatus Tendon Short Axis . . . . . . . . . . . . . . . . 18
Anterior Rotator Cu: Supraspinatus Tendon Long Axis . . . . . . . . . . . . . . . . 19
Gleno-humeral Intrarticular Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Chapter 5 - The Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Lateral Epicondyle Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Medial Epicondyle Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 6 - The Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Palmar Transverse Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Dorsal Metacarpal-Phalangeal Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter 7 - The Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Quadriceps Tendon Long Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Chapter 8 - The Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Plantar Fascia Long Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 5/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore4
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 6/34
Chapter 1Introduction
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 7/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore6
“Ultrasound imaging is not a passive push-button activity; rather it is
an interactive process involving a skilled clinician, patient, transducer,
instrument, and experienced interpreter. Understanding the physical
principles involved contributes to the quality of medical care involving
diagnostic sonography”
IntroductionDiagnostic ultrasonography as a general medical imaging modality has made
very great advances in the last 10 to 20 years within the medical profession.Now, appearing on the horizon, is the more frequent application of diagnostic
ultrasound to image musculoskeletal structures and the extremities of the body.
This manual is intended to provide an introduction to musculoskeletal scanning
protocols of the extremities, and hands-on use of diagnostic ultrasound.
The protocols presented are intended to provide a foundation from which
physicians and technologists can develop more advanced ultrasound scanning
abilities through education and experience in musculoskeletal ultrasound.
Sonography’s unique real-time capability, which permits examination during
movement, and allows guidance of biopsy needles, combined with the exquisite
resolution of state-of-the-art scanners and high-frequency transducers, makes
musculoskeletal sonography a powerful tool for diagnosing abnormalities of
the soft tissues. Musculoskeletal sonography has been underused because
of the availability of magnetic resonance imaging. However, sonography can
provide diagnostic information for only a fraction of the cost. In this era of costcontainment in health care, musculoskeletal sonography should be the rst
examination technique for many pathologic conditions of the soft tissues.
I feel condent that these protocols will provide physicians information to
improve evaluation and treatment of patients through valuable diagnostic
information obtained from the images.
1 | Introduction
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 8/34
Chapter 2Suggested Guidelines forMusculoskeletal Sonography
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 9/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore8
2 | Suggested Guidelines for Musculoskeletal Sonography
Equipment SelectionMusculoskeletal structures are long, striated and many times
layered tissues. Due to the striated morphology of these tissues
and their supercial location, high frequency, linear array
transducers are best suited for this application. It is recommended
that no less than 7.5 MHz transducers be used for musculoskeletal
examinations of the extremities. Ideally, 8.0 MHz and above
provide the highest resolution.
As in all ultrasound examinations, proper technical settings are
vital to the diagnostic value of the images. Musculoskeletal
images require adequate grayscale. Limited grayscale can lead
to diagnostic challenges. Refer to the manufacturer of yourequipment and their specic guidelines for optimal image settings.
Probe PlacementIt is very important to maintain accurate transducers placement in
musculoskeletal sonography. Due to the close proximity of several
distinct structures in a small area, a slight displacement of the
probe can produce inaccurate images. If the image states it is a
“midline” image be sure to be as close to midline as possible.
Image OrientationImage orientation is consistent throughout the manual.
Regardless of right or left.
Longitudinal views: left side of the image is CEPHALAD.
Transverse views: left side of the image is the PATIENT’S RIGHT
Suggested Exam ProtocolThe photographs in the manual clearly indicate patient and probe
positioning. All examinations do not need to be bilateral studies
that include identical images. It is not necessary to perform all
images described for each extremity in this manual on every
examination. Images may be performed specically in the area
of complaint. However, we recommend no less than 6 images per
exam. 3 transverse images and 3 longitudinal images.
Tips For Clinicians
Optimize your system for
proper grayscale. Almost all
images have identiable bo
landmarks. Visualize the bon
landmarks and the surroundi
soft tissue should also be
visible. Labeling of images
in this manual are merely
suggestions. Feel free to
establish a system of
labeling of images that is
best for your facility. To avoi
confusion, take care not to
make abbreviations too shor
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 10/34
3 Steps to
Successful Imaging
2 | Suggested Guidelines for Musculoskeletal Sonography
A Primer of Basic Musculoskeletal Images | Randy E. Moore9
Good images are aprerequisite for excellent
guided injections
1. Image GENERATION Patient & probe position, grayscale settings
2. Image RECOGNITION Identify Individual Interfaces from the bony cortex UP
to the skin surface!
3. Image INTERPRETATION Determine abnormal ndings by knowing normal!
Using a systematic,
STANDARDIZED approach
lets the clinician obtain
highly accurate anatomic
representation of the
anatomy.
The anticipated length
of the “learning curve” is
shortened. Confdence and
expertise is gained in a
shorter time frame.
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 11/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore10
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 12/34
Chapter 3Basic Normal MusculoskeletalUltrasound Anatomy
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 13/34
3 | Basic Normal Musculoskeletal Ultrasound Anatomy
A Primer of Basic Musculoskeletal Images | Randy E. Moore12
Skeletal Muscle
On longitudinal views, the muscle septae
appear as bright/echogenic structures, and are
seen as thin bright linear bands. On transverse
views, the muscle bundles appear as speckled
echoes with short, curvilinear bright lines
dispersed throughout the darker/hypoechoic
background.
Subcutaneous TissueSubcutaneous tissue is isoechoic (equal
brightness) with skeletal muscle. The dierence
between subcutaneous tissue and skeletal
muscle visualized on ultrasound is the septa do
not lay in lines or layers. More conspicuously;
a thick, continuous, hyperechoic band usually
separates subcutaneous fat from muscle.
Cortical Bone
On ultrasound examination, normal cortical
bone appears as a continuous echogenic (bright)
line with posterior acoustic shadowing (black).
Fascia
Fascia is a collagenous structure that usually
surrounds the musculotendinous areas of the
extremities. The fascia is then encompassed
subcutaneous tissue. Many times, the fascia i
seen inserting onto bone, and blending with t
periosteum. Normal fascia appears as a brou
bright/hyperechoic structure.
PeriosteumOccasionally, a thin echogenic line running
parallel with the cortical bone is demonstrate
on ultrasound. This is likely the periosteum.
However, in normal situations, the periosteum
is not visualized by ultrasound. Injuries to the
bone, especially those damaging the cortex,
periosseous soft tissues, and periosteum will
produce a periosteal reaction, which is visible
The following is a very basic introduction to normal
musculoskeletal anatomy on ultrasound, which is intended to
get novices started scanning quickly. For in-depth knowledge ofnormal and abnormal musculoskeletal anatomy, please consult one
of the many comprehensive textbooks on ultrasound examination
that are readily available.
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 14/34
3 | Basic Normal Musculoskeletal Ultrasound Anatomy
A Primer of Basic Musculoskeletal Images | Randy E. Moore13
Ligaments
On ultrasound examination, a normal ligament
is also a bright echogenic linear structure.
However ligaments have a more compact
brillar echotexture. Individual strands/bers
of the ligaments are more closely aligned.
Ligaments are composed of dense connective
tissue, like tendons, but there is much variability
in the amounts of collagen, elastin and
brocartilage within a ligament, which makes
its ultrasound appearance more variable than
tendons.
Bursae
In a normal joint, the bursa is a thin black/anechoic line no more than 2 mm thick. The
bursa lls with uid due to irritation or
infection. Depending on the extent of eusion,
the bursa will distend and enlarge; internal
brightness echoes are inammatory debris.
Peripheral Nerves
High-frequency transducers allow the
visualization of peripheral nerves that pass
close to the skin surface. Peripheral nerves
appear as parallel hyperechoic lines with
hypoechoic separations between them.
On longitudinal views, their appearance is
similar to tendons, but less bright/echogenic.
On transverse views, the peripheral nerves’
individual bers, and brous matrix, present
with multiple, punctate echogenicities
(bright dots) within an ovoid, well-dened
nerve sheath.
Tendons
A normal tendon on ultrasound examination is
a bright/echogenic linear band that can vary in
thickness according to its location. The internalechoes are described characteristically as
having a brillar echotexture on longitudinal
views. On ultrasound the parallel series of
collagen bers are hyperechoic, separated by
darker/hypoechoic surrounding connective
tissue. The bers will be continuous/intact.
Interruptions in tendon bers are visualized
as anechoic/black areas within the tendon.
Tendons are known to be anisotropic structures.
An / iso / tropy.
To not have equal properties/
characteristics/ appearances on all
axes. The property of being directiona
dependent. Produced when the probe
is not perpendicular with the structur
being evaluated. Most common artifa
in musculoskeletal ultrasound.
Anisotropy:
Denitions
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 15/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore14
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 16/34
Chapter 4The Shoulder
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 17/34
4 | Shoulder - Biceps Tendon Short Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore16
Biceps TendonShort Axis“Home Base”
The patient is seated with the
arm resting close to the side, and
the elbow is bent at 90 degrees,
resting on the patient’s lap.
The palm is turned up; but not
actively. Sometimes a pillow
is helpful when placed on the
patient’s lap.
Place the mid portion of the probe
in transverse orientation over
the PROXIMAL biceps region. By
carefully aiming the sound beam
the bright/echogenic contour of the
humeral head will become visible
Visualize the tendon within thebicipital groove.
LABELING: BIC SAX
Fig. 1 - Patient and probe position Fig. 2
Fig. 3 - SAX Biceps Tendon.
Greater Tuberosity
Humerus
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 18/34
4 | Shoulder - Biceps Tendon Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore17
Biceps TendonLong Axis
1. The biceps tendon is
examined in the longitudinal
orientation. Patient
positioning is unchanged
(seated with the arm relaxed
and the elbow exed).
2. From the proximal short axis
position, rotate the probe 90degrees. Align the humeral
cortex across the image.
3. Typically, medial translation
of the probe will visualize the
biceps tendon
LABELING: BIC LAX
Fig. 3 - Biceps Tendon Long Axis View.
Fig. 1 - Patient and probe position. Fig. 2
Humerus
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 19/34
4 | Shoulder - Anterior Rotator Cu: Supraspinatus Tendon Short Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore18
AnteriorRotator Cuf:
SupraspinatusTendon Short Axis
1. Place the probe in the
short axis orientation at
approximately the mid portion
of the humeral head. The
Supraspinatus is best seen
when the probe is parallel
with the oor.
2. The broad “dome-like”
convexity of the humerus
is identied.
Then the anechoic hyaline
cartilage covering the
humerus.
The thick/wide, bright/
echogenic arc is the brillar
pattern of the supraspinatus
tendon.
The thin/slender, dark/
anechoic area just above the
tendon is the subdeltoid/subacromial bursa in its
normal state.
LABELING: SSP SAX
A. Humeral Cortex
C. Supraspinatus Tendon
B. Hyaline Cartilage
D. Bursal Interface betweentendon & muscle
Fig. 3: Supraspinatus Short Axis
Individual - Interface - Identication
Fig. 1 - Patient and probe position. Fig. 2 - Arrows indicateSupraspinatus tendon.
D
C
B
A
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 20/34
4 | Shoulder - Anterior Rotator Cu: Supraspinatus Tendon Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore19
AnteriorRotator Cuf:
SupraspinatusTendon Long AxisThe “Two Part” Landmark
1. From the anterior short axis
position, rotate the probe to
be parallel with the humeral
shaft.
2. IMPORTANT! The “two
part “ landmark of the
greater tuberosity and
the humeral head ensure
adequate visualization of the
supraspinatus attachment
3. Viewing the image from left
to right, the supraspinatus
tendon resembles a “bird’s
beak”. The point of the “beak’
is the insertion of the tendon
onto the greater tuberosity of
the humerus. The anechoic/
black area on the attachment
surface is the tendon
“footprint”, which is normal.
* The “Critical Zone” is the 1
cm attachment area of the
supraspinatus tendon, where
90% of all rotator cu tears
are found.
LABELING: SSP LONG
Tendon “footprint”
Greater Tuberosity /Tendon Attachment
Humeral Head
Fig. 1 - Probe parallel to Humeral shaft. Fig. 2 - Arrows indicateSupraspinatus tendon.
Fig. 3 - Supraspinatus Long Axis.
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 21/34
4 | Shoulder - Gleno-humeral Intrarticular Injection
Gleno-Humeral Joint
A Primer of Basic Musculoskeletal Images | Randy E. Moore20
Gleno-humeralIntrarticular
InjectionPosterior Approach
1. The patient is in side posture
with the arm in full adduction
and internal rotation to
expose the posterior gleno-
humeral joint and labrum.
2. Position the probe in
a transverse/oblique
orientation, and slide it
inferior and medially toward
the axilla.
3. Inferior to superior probe
angle with adequate probe
pressure is necessary to
visualize the gleno-humeral
joint .
LABELING: POST GH SAX
Patient Position: Sideposture Internal rotationwith adduction
(A) Inf. GH Ligament(B) Axillary Pouch of GHL
Note SUPERIOR locationof Joint Capsule (C)relative to IGL
Glenoid Fossa
CA
B
Humerus GlenoidFossa
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 22/34
Chapter 5The Elbow
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 23/34
5 | Elbow - Lateral Epicondyle Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore22
Lateral EpicondyleLong Axis
1. Position the probe out on the
lateral aspect of the elbow in
long axis.
The bony landmarks are the
capitellum of the humerus
(proximal), and the radial
head (distal).
There should be a slight
exion of the elbow.
2. Just above the capitellum is
the insertion of the common
forearm extensor tendon, on
the lateral epicondyle.
LABELING: LAT EPI LAX
Fig. 1 - Longitudinal probe position onlateral elbow at the epicondyle.
Fig. 2 - The common extensor attachessuperior/proximal to capitellum.
Fig. 4 - Injection Setup. Fig. 5 - Example Procedure.
Fig. 3 - Common extensor tapers to its attachment on the lateral epicondyle which isproximal to the capitellum of the humerus.
Radial HeadHumerus
CommonExtensor
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 24/34
5 | Elbow - Medial Epicondyle Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore23
Medial EpicondyleLong Axis
1. The elbow is exed and arm
externally rotated.
The hand is actively
supinated. Ask the patient to
turn the palm up.
2. Place the probe in a
longitudinal plane on the
medial side of the elbow. Theproximal end of the probe is
then angled down towards the
table. The UCL should be
well visualized.
3. The common exor tendon
converges to attach on the
medial epicondyle.
LABELING: MED EPI LAX
Fig. 1 - Longitudinal probe position onmedial aspect with supination.
Fig. 2 A direct medial to lateral view ofthe medial epicondyle.
Fig. 3 - The thick, brous linear band of the common forearm exor is seen supercialthe triangular shaped ulnar collateral ligament.
UCL
Humerus
Ulna
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 25/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore24
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 26/34
Chapter 6The Wrist
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 27/34
6 | Wrist - Palmar Transverse Wrist
A Primer of Basic Musculoskeletal Images | Randy E. Moore26
Palmar TransverseWrist
1. The patient’s wrist is in a neut
position with the palm up. Usi
a cushion allows the wrist to
be relaxed.
2. Place the probe in short axis
across the wrist at the “CREAS
with the radial side being
the left side of the image.Use light probe pressure to
avoid compressing the nearly
subcutaneous nerve.
3. The exor tendons are in
compartments. They appear a
echogenic ovoid structures on
transverse examination.
4. The median nerve is supercia
to the exor pollicis longus
tendon, and distinguishable
by identifying its punctate /
pinpoint internal echoes. ie:
“starry night” or “honeycomb”
description.
5. Slowly ex the thumb, and
look for tendon movement. Th
median nerve will be superc
and to the right of the FPL.
LABELING: MN SAX
Fig. 1 - Supported wristNeutral position.
Fig. 2 - Median nerve is located toward theRadial aspect.
Fig. 3 - Ask patient to ex the thumb. Median nerve (MN) is above and right of theexor pollicis (FPL). Visualize bright, punctuate foci of nerve bers. “Starry Night.”
Median Nerve
RAD ULN
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 28/34
6 | Wrist - Dorsal Metacarpal-Phalangeal Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore27
Dorsal Metacarpal-Phalangeal LongAxis
A.K.A. MCP Joints Carpal-Metacarpal Joint
1. Place the probe in the
longitudinal plane over the MC
joint of interest.
The metacarpal head is rounde
with a NORMALLY occurring“notch” proximal to the joint.
2. The MCP Joint is frequently
aected in rheumatoid arthrit
as well as the PIP Joint.
Joint eusions, synovitis,
soft-tissue swelling can be
easily detected and monitored
with ultrasound. Cortical
erosions of the MCP Joint will
be plainly evident.
LABELING: DOR MCP LAX
Fig. 1 - Supported wrist Neutral position.
Fig. 2 - Longitudinal image of dorsal MCP. Yellow Arrow: normal cortical margin.
Fig. 3 - Out of PlaneInjection.
Fig. 4 - Tip of needle between arrows.
ProximalPhalanxDistal
Metacarpal
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 29/34
A Primer of Basic Musculoskeletal Images | Randy E. Moore28
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 30/34
Chapter 7The Knee
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 31/34
7 | Knee - Suprapatellar Bursa
A. Skin, subcutaneous fat, muscle
B. Quad Tendon
C. PRE-Femoral Fat Pad
D. Suprapatellar Fat Pad
E. Suprapatellar Bursa/Pouch
A Primer of Basic Musculoskeletal Images | Randy E. Moore30
Quadriceps TendonLong Axis
1. The patient is supine. The pro
is in the longitudinal position
with the inferior portion in
contact with the patella. The
cortical outline of the patella i
on the right of the image, with
the femoral cortex found lowe
on the left.
2. The hyperechoic quadriceps
tendon is composed of three
superimposed layers.
3. Noting the normal presence
of two (2) fat pads (g 2),
will help the examiner
evaluate the quadriceps
tendon. The suprapatellar
bursa is continuous with the
joint capsule. It is common
site chosen for intrarticular
injection.
LABELING: QUAD LAX
Fig. 1 - Supine pt. Slight exion. Fig. 2 - Quad tendon attaches topatella. Suprapatellar bursa is deep.
Fig. 3 - The thick, echogenic tendon is the convergence of four tendons.
Fig. 4 - Needle advanced to a thin bursalinterface
B
A
E
C
D
FH
Patella
Femur
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 32/34
Chapter 8The Foot
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 33/34
8 | Foot - Plantar Fascia Long Axis
A Primer of Basic Musculoskeletal Images | Randy E. Moore32
Plantar FasciaLong Axis
1. The patient is prone or kneelin
into a chair. The probe is in lon
axis, angled medially toward
the attachment onto the medi
tubercle of the calcaneous. Fig
2. Reading the image from the
cortical outline to the surface:
A. Plantar Fascia
B. Fibro Fat Pad
Musculature seen deep to
the fascia, and distal from the
calcaneous.
3. Plantar fasciitis is an extremel
common foot complaint in bot
the sporting and non-athletic
population.
LABELING : PF LAX
Fig. 1 - Prone or kneeling pt. Fig. 2 - PF attachment in green. Fat pad
supercial.
.
Fig. 3 - Long axis view of Plantar Fascia There should NOT be a bursa. Fluidaccumulation is abnormal. > 4mm thickness is criteria for fasciitis. Measurementsshould be taken at distal point of calcaneal apex.
Deep Flexors
PF
CAL
Fat Pad
8/12/2019 Uvod v MSK ultrazvok - Randy Moore
http://slidepdf.com/reader/full/uvod-v-msk-ultrazvok-randy-moore 34/34
Please visit us at: http:// www.mideas.si