Musculoskeletal Sonography of Hand, Wrist, and Knee PDF

MUSCULOSKELETAL SONOGRAPHY OF HAND AND WRIST OUTLINE Sonographic anatomy Technique Benign soft tissue lesions Tenosynovitis  Sonographic Anatomy Carpal bones (radial → ulnar) Proximal row Scaphoid, lunate, triquetrum, pisiform Distal row Trapezium, trapezoid, capit...

MUSCULOSKELETAL SONOGRAPHY OF HAND AND WRIST OUTLINE Sonographic anatomy Technique Benign soft tissue lesions Tenosynovitis  Sonographic Anatomy Carpal bones (radial → ulnar) Proximal row Scaphoid, lunate, triquetrum, pisiform Distal row Trapezium, trapezoid, capitate, hamate  R dorsal wrist ulnar radial L S tr. Wrist extensor tendons Extensor retinaculum defines six compartments ECU–Compart. 6 Each compartment E. digiti minimi–Compart. 5 E. Digitorum–Compart. contains a synovial 4 EPL–Compart. sheath for the 3 ECR Compart. B tendon(s) ECRL 2 APL Compart. EPB 1 Wrist extensor tendons 1 - Abd. pol. longus, ext. pol. brevis 2 - Ext. carpi radialis longus and brevis 3 - Extensor pollicis longus 4 - Extensor digitorum and indicis 5 - Extensor digiti minimi 6 - Extensor carpi4 ulnaris 3 2 5 6 1 Radiu s EXTENSOR TENDONS Wrist flexor tendons Flexor retinaculum forms carpal tunnel FPL, FDS, FDP Separate synovial sheath for FPL Invaginated sheath for 8 digitorum tendons Median n. Palmaris longus FDS FDP Ulnar FC a. Median n. R FP Ulnar L n. Radial a. FC U Radiu Uln s a FLEXOR TENDONS  Sonographic Technique High frequency linear array transducer 12MHz Tissue harmonic imaging Improves tissue contrast and spatial resolution Decreases side lobe and noise artifact Color/power Doppler Hyperemia Tumor vascularity Position Patient seated facing sonographer Wrist placed on an adjustable stand in neutral position Small rolled towel Scan technique Directed, dynamic study Longitudinal, transverse views LOTS of gel!  Benign Soft Tissue Lesions Ganglion Giant cell tumor of the tendon sheath Hemangioma Glomus tumor Nerve tumor Lipoma Epidermal inclusion cyst Nodular fasciitis Ganglion Most common lesion of the hand ≥ 70% of masses Mucin-filled, fibrous-lined cyst Etiology obscure Antecedent trauma in 10% No correlation with occupation Women > men Athanasian, Bone and Soft Tissue Tumors in Green’s Operative Hand Surgery, pp 2221-2237  Signs/symptoms Firm, palpable Pain, weakness (nerve compression) Occult dorsal ganglion Wrist pain without a mass Pressure on posterior interosseous nerve Sonographic findings Well-defined Non-compressible Anechoic Acoustic enhancement Debris Uni or multiloculated Cardinal, Radiology 1994; 193: 259-262  Dorsal ganglion ulnar radial L S R SL lig. - tr.  Dorsal ganglion distal prox. C S R SL lig. - long.  Ruptured dorsal ganglion distal prox. R capitate - long. Volar wrist ganglion (18-20%) Arise from Capsule of the radio-scaphoid joint Capsule of the scapho-trapezial joint FCR tendon sheath Athanasian, Bone and Soft Tissue Tumors in Green’s Operative Hand Surgery, pp 2221-2237  Volar ganglion FCR ulnar radial L wrist - tr.  Volar ganglion FCR distal prox. L wrist - long. Giant cell tumor (GCT ) of the tendon sheath Second most common hand tumor Benign soft tissue tumor Tumor cells resemble synoviocytes Women > men: 2:1 Peak incidence 20 to 40 years Athanasian, Bone and Soft Tissue Tumors in Green’s Operative Hand Surgery, pp 2239  Signs/symptoms Slowly enlarging firm nodule Usually nontender Location Arises from flexor tendon sheath Volar surface of digits IP or MCP joint levels Athanasian, Bone and Soft Tissue Tumors in Green’s Operative Hand Surgery, pp 2239 Sonographic findings Hypoechoic, solid Well-defined margins Internal vascularity Peripheral, central or both Adjacent bony erosion Bianchi, Skeletal Radiology 1999; 28: 121-129 Middleton, AJR 2004; 183: 337-339  GCT of tendon sheath radial ulnar R 4th digit - tr. PIP, volar  GCT of tendon sheath distal prox. R 4th digit - long. PIP, volar Hemangioma 10% of benign hand tumors Women = men Peak incidence 20-40 years Signs/symptoms Slowly growing painless mass Bluish discoloration of the skin Kransdorf, MRI CNA 1995; 3: 327-344  Sonographic findings Hypoechoic solid mass Phleboliths (rare) Rubbery, compressible Well-defined margins Hypervascular Low resistance arterial flow Högland; Ultrasound in Imaging of the Wrist and Hand; pp 479-498  Hemangioma radial ulnar R 3rd/4th digits - tr. Web space  Hemangioma dista prox l. L 4th digit PP, volar Glomus tumor 50% of cuff) can be mistaken for a full thickness tear  R partial SS tear - long. med. lat.  R partial SS tear - tr. ant. post. BT  R partial SS tear - long. med. lat.  R partial SS/IS tear - long. med lat.. Misinterpreted as full thickness tear  L BT sheath effusion - tr. med. lat.  L BT sheath effusion - long. sup. inf.  R SDB effusion - ant. C lat. med.  R SDB effusion - long. med. lat. GT R SDB/BT sheath effusions - long sup. inf. R SDB/joint effusions - post. med. lat. IS Hum. head  Biceps Tendon Pathology Inflammation/tear/rupture Instability Inflammation/tear/rupture Associated with painful RCTs Etiology Location in impingement zone Susceptible to inflammation from joint overuse Hypertrophy Chronic inflammation Inflammation Tenosynovitis, tendinitis Increased power/color Doppler flow in tendon or sheath Low sensitivity for tendinitis, tenosynovitis Sheath fluid  R BT tenosynovitis - tr. lat. med.  R BT tenosynovitis - long. sup. inf.  L BT tenosynovitis - tr. med. lat.  L BT tenosynovitis - long. sup. inf.  Partial thickness BT tear Low grade Low sensitivity High grade (≥ 70% tear) Misinterpret as rupture Rupture of BT Nonvisualization of BT Contracted biceps muscle US very accurate for diagnosing BT rupture  L BT rupture - tr. med. lat.  L BT rupture - long. sup. inf.  Contracted L biceps muscle sup. inf.  Normal R biceps muscle sup. inf.  Contracted L biceps muscle sup. inf. Instability (luxation) Main restraint to BT subluxation and dislocation Prevalence of luxation: 16-20% Partial displacement out of groove (subluxation) Anterior or medial to lesser tuberosity (dislocation) US very accurate for diagnosing subluxation/dislocation  R BT subluxation - tr. lat. med.  L BT dislocation - tr. med. lat.  L BT dislocation - tr. med. lat. KNEE SONOGRAPHY  KNEE SONOGRAPHY OUTLINE KNEE ANATOMY TECHNIQUE ANTERIOR LATERAL MEDIAL POSTERIOR PATHOLOGIES Gross Anatomy Sonographic technique Anterior- approach Lateral approach Medial approach posterior approach 3/17/2023 Anterior Courtesy JW 3/17/2023 Medial Courtesy JW 3/17/2023 Lateral 3/17/2023  Courtesy JW 3/17/2023 PATHOLOGIES  Lower Extremity/Knee Bakers’ cyst Meniscal tear Quadriceps/patellar tendon tear Joint effusion Gastrocnemius musculotendinous tear Muscle hernia  Baker’s cyst Haemoathrosis 3/17/2023  Loose bodies in a Baker’s cyst 3/17/2023 Ruptured Baker’s cyst 3/17/2023 Bursitis of deep infrapatella bursa 3/17/2023  Meniscal tears 3/17/2023  Crushed meniscus 3/17/2023  Meniscal cyst 3/17/2023 Meniscal cyst & hypoechoic meniscus 3/17/2023  Partial tear of the medial collateral ligament 3/17/2023 Partial tear of the quandriceps tendon 3/17/2023 Patella tendinosis 3/17/2023  Patella tendinosis AJR 2000; 175:1313-1321 3/17/2023  :Sonogram illustrates fracture of the right medial femoral condyle in a 37-year old following a motor accident. 3/17/2023  Avulsion fracture 3/17/2023 Quadriceps tendon tear Etiology Trauma (fall on partially flexed knee) Spontaneous (knee arthroplasty) Systemic disease SLE, RA, gout, DM, CRF Signs/symptoms Limited knee extension Pain, swelling distal thigh Sonographic findings Complete rupture Disruption of tendon fibers Fluid, hemorrhage in gap Distal traction on patella ↑ gap between tendon ends Partial tear Focal defect Bianchi, AJR 1994; 162: 1137-1140  Quadriceps rupture prox. distal L - long.  Quadriceps tendon rupture prox. distal R - long. Partial quadriceps tendon tear prox. distal R - long.  Patellar tendon rupture prox. dist. R - long. Gastrocnemius musculotendinous tear Etiology Extension of the knee and forced dorsiflexion of the ankle Sprinting, soccer, football, baseball, tennis, jogging Sonographic findings Disrupted distal medial head of gastrocnemius at musculotendinous junction Fluid, hemorrhage in gap Anechoic linear cleft along aponeurosis between gastrocnemius and soleus muscles Hemorrhage Medial distal gastrocnemius rupture prox. distal L calf - long.  Hemorrhage - gastroc./soleus gastroc. prox. soleus distal R calf - long. Hemorrhage - gastroc./soleus R L Calf - long.  Summary US is a useful test to evaluate the hand wrist, shoulder and knee joints Patient age/gender, history, lesion size, signs/ symptoms, combined with US findings can provide an accurate diagnosis