M usculoskeletal sonography is a
rapidly evolving technique that is
gaining popularity for the evalua-
tion and treatment of joint and soft-tissue dis-
include accessibility, quick scan time, low
cost, multiplanar capability, and the ability to
perform dynamic real-time imaging with con-
tralateral comparison. Advances in technology
Doppler sonography, and extended field-of-
view function have facilitated the progressive
development of sonography [13].
One notable drawback of sonography is op-
eases. Inherent advantages of sonography with higher frequency transducers, power erator-dependency; the quality and consistency
A B
C
Fig. 2.30-year-old woman without symptoms. Longi- Fig. 3.60-year-old man with muscle herniation caused by remote trauma.
tudinal sonogram reveals normal ulnar collateral liga- A, Longitudinal sonogram of anterolateral lower extremity, in region of focal bulge, reveals herniation of anterior
ment (black arrows) of elbow. Note medial epicondyle tibial muscle (white arrows) through defect in fascia (black arrows).
(M and white arrows) and proximal ulna (U and arrow- B, Longitudinal split-screen sonogram obtained in same location as A shows minimal motion of anterior tibial
heads). d = distal. muscle with dynamic imaging between dorsiflexion (left-sided image) and plantar flexion (right-sided image).
Note muscle herniation (solid arrows), fascia (open arrows), and small subfascial fluid collection (asterisk).
C, Longitudinal split-screen sonogram shows comparison of muscle echotexture between scarred, herniated
symptomatic leg (left-sided image) and normal contralateral asymptomatic leg (right-sided image). Note fascia
(open arrows) and muscle herniation (solid arrows).
General Principles and orientation of the nerve but can usually A thin hypoechoic rim paralleling the
When performing musculoskeletal sonog- be identified by the nerve distribution. echogenic articular cortical surface repre-
raphy, the proper equipment is essential to On sonography, the bone cortex appears sents hyaline cartilage (Figs. 1 and 6). Ongo-
facilitate optimal image quality and diagnos- as an echogenic surface with posterior shad- ing research on the potential clinical
tic examinations. In general, the structures owing (Fig. 1). Only the superficial surface applications of sonography of fibrocartilage
examined will be superficial; therefore, high- of the bone can be consistently evaluated on is promising. Sonography may play a more
frequency ( 712 MHz) linear array trans- sonography. Radiographically occult frac- significant role in the assessment of labral
ducers are usually the most appropriate tures can be detected on sonography, seen as and meniscal lesions as technology contin-
choice. The high resolution attainable allows a step off cortical disruption [1, 7] (Fig. 5). ues to improve [1] (Figs. 7 and 8).
detailed anatomic depiction of pertinent
structures [1]. Proper positioning of the pa-
tient is of paramount importance in obtaining
high-quality studies. Different sonographic
techniques have been described, with the
universal goal of optimizing the visualization
of structures of interest.
Calcifications typically exhibit increased and the patient is invaluable. Additional clin- related to specific positions or movements,
echogenicity with associated posterior acous- ical history about the precise location and which can be absent during static examination
tic shadowing (Fig. 9). However, the presence character of symptoms, direct feedback [2] (Fig. 11).
of shadowing depends on the size of the cal- about tenderness with probe palpation, and Compression from applying transducer
cification [8]. When calcification is present positions or movements that elicit or aggra- pressure under real-time visualization can re-
within the substance of a tendon, it com- vate symptoms can assist in the accurate in- veal important information about the compo-
monly represents calcific tendonitis (Fig. 10). terpretation of findings. sition of underlying structures and allows
The flexibility and dynamic capability of increased conspicuity or detection of abnor-
Examination sonography allow a targeted examination, spe- malities that may be otherwise hidden [2]
Although sonography is operator-depen- cific for each individual. Dynamic imaging (Fig. 12).
dent, the interaction between the examiner can readily reveal certain transient conditions Contralateral comparison is easily per-
formed in the musculoskeletal system; it dis-
tinguishes significant findings from normal
variants and occasionally reveals unsus-
pected abnormalities, which can be crucial to
the treatment of a patient (Figs. 13 and 14).
Technical Features
Color and power Doppler sonography fea-
tures show the degree of vascularity associ-
ated with inflammatory processes and solid
masses. Power Doppler sonography can be
used to characterize musculoskeletal inflam-
mation in cellulitis, abscess, synovitis, myo-
sitis, and bursitis [9] (Fig. 15).
The split-screen function that is available
on most sonography units can expand the
field of view to approximately double the
width or can be used for side-by-side com-
parisons (Figs. 13 and 14). The extended
Fig. 5.36-year-old woman with patellar fracture. Longitudinal sonogram shows mildly displaced fracture of patella field-of-view function, available on the
(arrows) that was not revealed on radiographs of knee. p = proximal, d = distal.
Sonoline Allegra sonographic unit (Siemens
Medical Systems, Iselin, NJ), can display
very large continuous sections of anatomy,
Fig. 6.80-year-old woman with rotator cuff tear. Transverse sonogram reveals small full-thickness tear (curved ar- Fig. 7.37-year-old man with shoulder pain. Trans-
rows) in distal supraspinatus tendon. Note hypoechoic hyaline articular cartilage (black arrowheads) of humeral verse sonogram of posterior glenohumeral joint shows
head. Fluid present within defect of supraspinatus tear accentuates echogenicity at surface of hyaline cartilage normal posterior glenoid labrum (arrows). Note gle-
(white arrowhead ). a = anterior, p = posterior. noid (G) and humeral head (H). Pain was caused by
torn rotator cuff tendon (not shown).
preserving spatial resolution without distort- Fig. 9.27-year-old woman with dermato-
ing structural relationships [10, 11] (Fig. 16). myositis. Transverse sonogram of medial
upper arm in region of several small non-
Recent innovative functions such as three- tender palpable nodules shows several
dimensional imaging (Fig. 17) and tissue subcutaneous echogenic foci (arrows)
harmonics (Fig. 18) may provide further im- with distal shadowing (arrowheads) that
represent superficial calcifications.
provement in the diagnostic effectiveness of
sonography. The role of these functions in
the assessment of musculoskeletal disorders
is currently under investigation [3].
Artifact
Anisotropy is an important artifact that can
affect the image and should be considered
when examining any musculoskeletal soft-tis-
sue structure. This finding is most obvious with
tendons and ligaments, caused by the highly
A B
Fig. 10.21-year-old man with calcific tendonitis of Achilles tendon.
A and B, Longitudinal (A) and transverse (B) sonograms of Achilles tendon at distal insertion reveal extensive calcifications (white arrows) within tendon, consistent with calcific ten-
donitis. Note distal shadowing (arrowheads), and note superoposterior aspect of calcaneus (C and black arrows) in A. p = proximal, d = distal, m = medial, l = lateral.
A B
Fig. 11.50-year-old man with intermittent ulnar nerve subluxation.
AC, Transverse dynamic sonograms of cubital tunnel region reveal tran-
sient dislocation of ulnar nerve (black arrows) out of cubital tunnel (white
arrowheads) with progressive flexion. Note medial epicondyle (white ar-
rows) and origin of common flexor tendons (black arrowheads), which
appear hypoechoic because of anisotropy artifact (see Figs. 17 and 18).
v = volar.
A B
Fig. 16.68-year-old woman with large hematoma caused by falling. Longitudinal Fig. 17.66-year-old woman with left shoulder pain. Three-dimensional image of intact
extended field-of-view sonogram of anterior aspect of right leg reveals large pretibial long head of biceps tendon with joint effusion extending into bicipital tendon sheath shows
hematoma (black arrowheads), which measured 10 cm in length. Extended field-of- three standard orthogonal planes: axial (solid arrowhead ), coronal (straight arrow ), and
view function allows full coverage of this lesion. Note tibial cortex (arrows). Mirror- sagittal (open arrowhead). Oblique plane (curved arrow ) was chosen by sonographer. Clin-
image artifact (white arrowheads) is present. p = proximal, d = distal. ical use of this function for musculoskeletal sonography is under investigation.
A B
Fig. 18.62-year-old man with left shoulder pain. L = lesser tuberosity, G = greater tuberosity.
A, Standard transverse sonogram of long head of biceps tendon is poorly visualized because of deep location of biceps tendon caused by large body habitus of patient.
Note bicipital groove (arrowheads).
B, Transverse sonogram with tissue harmonics function reveals intact long head of biceps tendon (arrows) discretely in bicipital groove (arrowheads).
A B
ordered, parallel pattern of collagen fibers that specular reflectors and an artifactual hypo- When a tendon has a curving course, the effects
shows the greatest degree of reflectivity when echoic to anechoic appearance [4] (Figs. 19 and of anisotropy cannot be entirely eliminated.
examined perpendicular to the ultrasound 20). The sonographer should be aware of Each separate portion of the tendon must be ex-
beam. Anisotropy occurs when the ultrasound proper transducer position and may need to amined individually, and the evaluation of ten-
beam is not perpendicular to the fibrillar struc- manipulate the heeltoe and foreaft angula- don integrity should be primarily determined
ture of the tendon, resulting in the absence of tion of the probe to avoid this artifact [12]. during real-time scanning.
A B
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