How To: Musculoskeletal Ultrasound of the Upper Extremity - HD

Introduction to Dynamic Ultrasound Imaging of the Upper Extremity

Hello, welcome to Sun World.
I'm Dr. Tony Var.
Sun World has been kind enough to invite me to talk
to you about the dynamic ultrasound imaging
of the upper extremity.
Dynamic imaging is very important
to when you look at the musculoskeletal system,
especially since you can see the entire extent
and rotation of all the structures
that you're supposed to explore.
We're going to look
at the entire upper limb today from the shoulder
down to the fingertips.
And now we can begin by looking at the all important
shoulder for the dynamic imaging
of the musculoskeletal system.

Dynamic Imaging of the Shoulder

Let's begin with a shoulder,
which is the most requested examination
here in the United States.
Mike, who's going to look at you right now is our model
and that we're going to begin
by looking at a four quadrant approach.
Off the shoulder, we're going
to look at the anterior quadrant, the superior quadrant,
the lateral quadrant, and the posterior quadrant.
And the anterior quadrant will begin
by showing you several dynamic explorations
of the anterior region of the shoulder.

Anterior Quadrant

We begin by putting the probe transversely across the
patient's upper arm
and locating the bone acoustic landmark
of the long bicipital tendon and the bicipital groove.
You could see that long bici tendon is central
within the bicipital groove.
We're going to first test the location
and the stability of the long bici tendon in
short axis mainly,
but it's always important to recognize
that this has a filar pattern in the long axis,
therefore is compatible with a tendonous structure.
You go back to the short axis view
and we're going to ask our model Mike to go ahead
and swing his hand and forearm outwards
and as he swing outwards, notice
that the long bici tendon stays within the bici groove.
One important thing as he cycles through the internal
and external rotation is you do have to follow
the long bici tendon within the bici groove.
And one of the things you have to remember is
that you cannot apply too much compression,
so you have to lighten up.
Otherwise you may trap a subluxing long bicipital tendon.
So the first dynamic imaging
that you see in the sonar world tape is the maneuver
in order to see if the long bicipital tendon sublux is out
off the bicipital groove.
We continue the cyclic motion that Mike is doing
and we're going to move to the medial area.
We're going to adjust the depth a bit so you begin
to appreciate the coracohumeral distance and space.
Here you see the bone acoustic landmark of the corco process
and as he cycles through, notice
that now we expose the entire subs capillaries.
Also, as he internally rotates, note again the distance
between the bony corticoid process and the subs capillaries.
We're gonna ask Mike to cycle closer to his abdomen
as he internally rotates his arm.
And that space
that you see is gonna be the corco humeral space.
So the second dynamic imaging
that you're seeing in the anterior region of the shoulder
is going to be where you could have a
corco humeral impingement.
Often if there's thickening
of the sub chromal subdeltoid bursa
or tendinosis of the subs capillaries,
this could now impinge within the space.
The other maneuver, aside from internal external rotation
of the cortical humeral space, is to ask Mike now
to put the his right hand on top of his left shoulder.
This cross chest maneuver also exaggerates the
corco humal distance.
So here now you could see as he does that,
therefore we begin to appreciate
that it could impinge not only the subs capillaries,
but also the subacromial subdeltoid burin.
So this would be at least three types of maneuvers
that you have to look at.
The anterior shoulder, the subluxing
long occipital tendon, the
impingement of the corco humal area,
and of course the collision of the
lesser tuberosity onto the corco process.

Superior Quadrant

Now we're going to go to the superior
quadrant of the shoulder.
The second quadrant in the dynamic imaging
of the shoulder is going to be the superior region,
and we're going to be taking a look at the
acro vicular joint.

Acromioclavicular Joint

We are going to put the transducer on the vertex
of the shoulder, which is the highest point of the shoulder,
and here you see the bone acoustic landmark of the acromion
and then the clavicle.
And right in the middle where you see the distance
between the two subarticular plates is the joint space.
The acromioclavicular joint in a dynamic motion is going
to be examined by asking the model
to bring his right hand onto the top
of his right left shoulder.
And as he goes to that cyclic motion, you'll notice
that there is a translation in the coronal plane
of the distal head of the clavicle towards the acromion.
However, there is no collision
nor impaction of the distal clavicle
onto the acromion.
The abnormality often found in this region is going
to be the superior subluxation of the distal clavicle
as the model continues to cycle superiorly in relation
to the bone acoustic landmark of the acromion.
And so what you want
to see in this area is a sudden upward jump of the clavicle
in relation to the acromion.

Sternoclavicular Joint

Another area of dynamic imaging
that will require exploration with an ultrasound is going
to be the sternal clavicular joint.
Patients may complain of a small bulging or even some pain
and some swelling on that region.
We're going to take a look at the acoustic landmarks
of the sternal clavicular joint.
Here you see the medial aspect of the clavicle,
and as you go a little bit more inferior now we begin
to see the clavicle, the joint line,
and then you see the top of the manubrium,
which is the ubal notch.
So now we're going to just leave the
transducer in this area.
The maneuver that we're going to ask from our model is
to bring both hands behind him
and cla his hands against his back,
and then we're going to be asking him to lift
his hands off his back
and that should put stress on the
sternal C clavicular joint.
So he is going to go back where he has his hands clasped
behind him and it's going to be pressed against his back.
This is the right sternal clavicular joint
and you can always compare it to the left
sternal clavicular joint.
Here you could see part of the clavicle, the ubal notch.
We're going to explore the right side now where you see the
sterno clavicular joint,
we're gonna ask our model now to go
through the cycles wherein he's going
to lift his hand off from his back
and notice a minimal distraction of the joint
and then back again as is going through the cycle.
Note how stable this joint is.
What you will appreciate in this examination if it's
abnormal, would be the anterior subluxation
of the medial head of the clavicle in relation to the manum
of the sternum for a sternal ubal type
of subluxation dislocation.

Lateral Quadrant

The third of four quadrants is going
to be the dynamic imaging of the subacromial space
where we may see entrapment of the
supraspinatus impinging on the undersurface of the acromion.

Subacromial Space

We're going to place the probe in a coronal plane in the
long axis view of the supraspinatus along the entire plane
of the patient's scapula.
As we do that now we're going to ask the patient
to raise his arm
and hand towards my elbow at a 45 degree,
and you could see how smoothly the three units
of the supraspinatus go.
In the three units are the bone acoustic landmark
of the greater tuberosity.
The second unit is the fi pattern
of the supraspinatus tendon, which has a pared beak contour.
The third unit will be the subacromial subtype
bursa in this maneuver.
Therefore, what is going to appear abnormal
is if the entire three units cannot
with the friction at all, go
underneath the subacromial space.
Note the bone acoustic landmark of the acromion,
which has no lateral type of subacromial spur.
When you look at this type of maneuver, you'll appreciate
that there is normal motion.
A abnormal cogwheel
cogwheel translation will tell you
that there is subacromial impingement.
In addition, it all depends on
where the abnormality might be.
Right now our model mic is raising it at 45 degrees
between the anterior and lateral planes of his body.
If there was an abnormality in the anterior plane,
then you may well move your transducer a little bit more
anteriorly and then ask the model
to raise his hand anteriorly in front of him.
And this is how you'll try to catch the abnormality,
another modification of this motion.
Now, instead of extending his arm,
we're gonna ask him just merely to bend his elbow
and raise his elbow towards my arm.
And again, you are duplicating
and reproducing the subacromial translation
of the greater tuberosity, supraspinatus
and subacromial subdeltoid person
still in the lateral
or more like anterolateral area of the shoulder.

Coracoacromial Ligament

In the four quadrant display on the lateral quadrant,
we're going to take a look at the corco acromial ligament,
which is the roof for the rotator cuff, mainly
for the supraspinatus.
We're going to identify the bone acoustic landmark of the
cricoid and that of the acromion.
And once we have the compact fibrile pattern
of the ligament, we can now examine the
corco acromial ligament.
We're going to direct the probe directly immediately
below this ligament.
And now you can identify the rotator cuff.
We're gonna ask micro model to go ahead and internally
and externally rotate his elbow.
And as you see the translation of the tendon,
you could immediately appreciate the fact that it's gliding
underneath the cortical acromial ligament.
Any bumpy motion of this glide
or any obstruction which may buckle
or push the ligament outwards will confirm
that there is underneath the corco
acromial ligament, an impingement of the immediately
adjacent rotator cuff.

Posterior Quadrant

The fourth of the four quadrant exploration
of the shoulder is going to be the posterior shoulder
where we're going to look for the glenohumeral joint.
Look at the ball and socket maneuver off the area,
and also we're going to try to show if there is going
to be an internal impingement during those motions,
we'll begin by putting the probe transversely across the
model's back and adjust the depth.
Since it's a deeper structure here,
you appreciate the convexity of the humerus
with articular highline cartilage
and then the bone acoustic landmark of the glenoid socket
on top of the glenoid socket.
You can now appreciate the triangular fiber cartilage
of the glenoid labrum for confirmation
that we're indeed in the glenohumeral joint.
We're going to ask our model now to swing his hand
and forearm outwards
and then back in towards his abdomen.
And now you can appreciate the ball and socket motion.
This dynamic imaging as he externally rotates,
will exaggerate any glen humeral effusion.
So that's one of the first things you should take a look at.
Aside from the very smooth gliding
and congruity of the glenohumeral joint
as he continues to do that, we're now going to look
for changes that may imply
or lead to the suspicion of an internal impingement.
First you look at if there's any contour deformation
of the triangular contour of the glen
of the posterior superior glenoid labrum.
Here you see that the apex is mildly indenting,
but that's about all
that's happening in this professional model.
The second thing you're going to look for
is the normal variant bare area off the shoulder
and see if it is deepened or widened.
So as you continue to look now there are several findings
that may begin to lead to the suspicion
of internal impingement.
Note that the bear area is a bit deeper.
Second, that it begins to
impale on the apex of the labrum.
And so those are two of the three findings.
The triad that will tell you
that the patient may have internal impingement isn't first
a contour deformation of the glenoid labrum, a deepening
of the bare area.
And finally, undersurface frame of the infraspinatus.
So here we're going to see the fibrillar pattern
of the infraspinatus,
and now we're going to ask the patient to go ahead
and externally rotate his shoulder to see
how much impaling you see with the glenoid labrum.
Note that the infraspinatus bunches up normally
and there is no hypo coic defects noted in
the infraspinatus.
The modification of the motion now is exactly
what the model is doing we're in.
We get to see that as he pretends to throw the ball,
he straighten out his arm and we're back to normal.
But as it does the a bear abduction external rotation,
note again how the bear area off the shoulder
is going to impale into the glenoid.
But again, at this point, not scuffing the infraspinatus.
We're gonna ask the patient now to pause
and do this in stages.
First we're gonna start from neutral position.
He's gonna bring his arm down towards his side
and rest his elbow
and forearm in the neutral position in stages.
Therefore, first we're gonna ask him
to raise his elbow outwards.
Next we're gonna ask him to bring his hand back
as if he was throwing a ball.
Third, we're gonna ask him
as he was throwing the ball forward.
So those are the three stages
that you could look at the individual.

Dynamic Imaging of the Elbow

The dynamic exploration of the elbow will entail, again,
probably looking at it in four quadrant display,
but it's only in the anterior quadrant, the ulnar quadrant
or the medial quadrant and the posterior quadrant
where we'll be looking for changes that may occur
around the elbow many times if it's a bit more dedicated
than the fourth quadrant, which is going
to be the radial quadrant is also going to be explored
for radial collateral ligament tears.
So on the basic exploration of the elbow,
what is most important now is to identify the
medial collateral ligament.
We're going to look for the anterior bundle
of the medial collateral ligament.
There's no space between the medial
elbow and that of the table.
So with a rolled up towel, we're going to bolster the elbow
where now I have sufficient space.
In order to look for the anterior bundle
of the ulnar collateral ligament, we are going
to identify the bone acoustic landmark of the epi tral
and connect it to the sublime tubercle
in the coronary process.
Here you see at the top of the image, the apex
of the troia down to the ulnar notch
into the tro clear area of the humerus.
Then you see the joint space
and then the shark fin shape of the coronary process
where you now have the nipple like sublime tubercle
as you connect the two bony structures of the troia
and that of the coronary process.
Now you see a pact fibrile pattern
representing the anterior bundle
of the ulnar collateral ligament.
Once you've identified that, then you could apply a
valgus stress in order to stretch the ligament
and open up the joint space if you need to.
The other modification of this maneuver is in orthopedics.
You put the patient in again, some 30 degrees of flexion.
Here you one more time.
You can identify the anterior bundle
of the ulnar collateral ligament.
You're going to possibly show what's going on
by grabbing the thumb of the patient
and do the Laura timberman type of maneuver.
Or in now you could do a valgus stress
and you stretch the ligament
and also try to see if you can open up
the UL noal joint.
Those are the two criteria, a disruption of the
PAC Fibrile pattern of the ulnar collateral ligament
and a widening of the joint space
of the ulnar truckle region.
A continuum of the medial quadrant to dynamic imaging
of the elbow is
after you have evaluated the ulnar collateral ligament is
to look for the cubital segment of the ulnar nerve.
We're going to identify the bone acoustic landmark of the
troia in short axis.
Then we're going to look for theone process.
I'm going to move the patient a little bit more medially
to give a little bit more space
because the table is hampering the cable end
of my transducer here.
Now you see in the cubital tunnel, right behind the apex
of the troia is a honeycomb structure representing the
all our nerve within the cubital tunnel.
In the short axis view, the dynamic imaging that we're going
to proceed with is to do an inflection
and extension of this region.
So this is the motion that the patient is going to have
and be doing while he is going to show you the cyclic motion
on an active type of procedure.
I'm now going to add a bit more gel.
I'm going to let go of the transducer,
let the model show you the flexion and extension.
In addition, at the end of his flexion motion, I'm going
to ask him to pump his elbow just in case we get
to see a snapping tricep syndrome.
I'm going to now plant my transducer on the troia.
Here you see the electron at the bottom
and that the ulnar nerve stays behind the apex
of the troia.
So this is the dynamic motion
that you would require off your patient to see if
that ulnar nerve, which is the hypo coic honeycomb pattern,
sublux is anterior to the troia.
In this case, for example, this is the normal position
of an intact and normal
ulnar collateral ligament within the cubital tunnel.
The third of a four quadrant display examination
of the elbow will be the exploration
of the radial collateral ligament.
We're going to put the patient in a pronation
and identify the radio collateral ligament by going
to the poster lateral corner off the elbow.
And once you have identified the common extensor tendon
origin of the patient,
identify the poster lateral corner off the radial head,
we're going to put the elbow in 30 degree flexion.
And here you could see mostly the common extensor tendon
inserting onto the radial epicondyle
and you here, you could also appreciate at this level
the difference in echogenicity of
what is the radial collateral ligament
and that of the fibrillar pattern of the tendon.
A various stress against the corner of the table will show
that you are stretching the radial collateral ligament.
This is the maneuver that will accentuate
any defects of the radial collateral ligament.
The anterior quadrant dynamic imaging
of the elbow will entail looking at the
distal biceps tendon.
A lot of people look at it in the long axis view.
They identify the long, the distal biceps tendon
by taking a look at the radio Capella joint.
Move over to the radial neck and then the radial tubercle.
Then they ask the patient to hyper supinate
by turning his thumb down.
Then the examiner moves the transducer to the medial aspect
to edify the radial tubercle with a little bit
of heel toe maneuver.
Now you could see the nice fibular pattern
of the distal biceps tendon inserting
on the radial tubercle.
In addition, you begin also to see the neck of the radius
and the radial head itself.
There's a little bit of partial volume averaging
with the brachial artery.
So this approach shows if there's any discontinuity,
then you want to see the tendon evolves from
the radial tubercle.
This approach is great when you're looking for discontinuous
distal biceps tendon.
The other approach that's been published
by the folks at Mayo Clinic is going
to be looking at the distal biceps tendon in a coronal view.
We begin by identifying the troia,
the ulnar notch move, the transducer distally,
and as you do so on the deeper portions of the image,
you begin to come onto the brachial artery and deep to that.
Now is the Pac fibular pattern of the distal biceps tendon.
We'll adjust the depth of the transducer,
and so the hypo coic tubular structure
is the brachial artery,
and underneath that is going to be the febrile pattern
of the distal B of tendon
with a pronation supination maneuver.
Now you get to see in the coronal plane the motion
of the distal biceps tendon.
Also, you see at the extreme right, the radial tubercle.
This type of dynamic imaging would work best
for partial thickness tears in comparison
to the direct approach of the long axis view
of the distal biceps tendon.

Dynamic Imaging of the Hand and Fingers

For the hand and fingers, it's the same four quadrant,
display where in the extensor region is on
the dorsum of the hand.
Then you have the flexor region, which is another quadrant
that you could look at.
Then you have the radial area for, especially
for the first compartment of the extensor region
for decar veins, disease.
And last but not least,
you can take a look at the fourth quadrant
for the Accenture Carpe nerves
and the distal radio ulnar joint.
The acronym is drudge.
We begin by looking at the area
that is most commonly affected
by taking a look at the carpal tunnel.
We're going to identify the median nerve in the long axis
view by looking at three bones.
Your bone acoustic landmarks are going
to be the radius lunate and capitate.
We're going to ask micro model to put his
hand flat on the table.
And we're going
to take a peek again at the bone acoustic landmark
of the radius lunate
and the peanut shape capitate.
Once you've identified that,
you'll see the inter collated fiar pattern
of the flexor tendons,
and then a fascicular pattern representing the median nerve.
I'm going to move the focus to look at the median nerve.
Mostly. I'm gonna go a little bit more distal,
maintaining again the three bones in tandem radius,
lunate and capitate.
I'm going to hold back the three fingers
of our model and ask him to curl his index finger.
And as he curls his index finger,
you'll notice the translation of the tendons.
While it's going through that cyclic motion, you'll notice
that the fibrillar echo structures presumptive
of tendons are the ones translating proximal to distal
while the median nerve just bounces along with it,
but no translation.
This would be, again, very important
to see if there's anything trapping the motion, not only
of the tendons,
but if there's anything that is clinging on
to the median nerve.
Same thing can be seen in short axis view
as we look at the median nerve In order to identify it,
let's take advantage of the onis atrophy off tendons
by taking a look at the tendons, make them hyper coic.
We're going to focus again on the median nerve,
and you could see that the index tendon, the
flexor tendons, are immediately
below the honeycomb pattern off the nerve.
So this is one dynamic motion that's very important.
In addition, we could see that some of the lumbrical muscles
might invade this carpal tunnel region,
where now it could be in a space occupying lesion here.
One more time. You appreciate the translating
flexor tendons, both deep
and superficial of the index finger
and a relatively preserved median nerve.
This would be the dynamic imaging most often
wherein we initially evaluate the median nerve,
but in actuality, as the cameraman zooms out, most
of the natural type of work that occurs is going
to be in supination, excuse me,
in pronation rather than supination.
We're now going to leave the transducer this way,
and we're going to ask the model now for Mike to go ahead
and press all his fingertips together
and look at the translation of the median nerve.
I'm going to lift his hand up a little bit more,
locate the median nerve again against the tendons
and press his fingers together
and to see if there's any translation of that median nerve.
Notice that it has a mild rotatory composition
or translation,
but does not get entrapped within the carpal tunnel region.
As we look at it, again, as he looks at his fingertips
and as he closes them together,
you see the normal translation of the tendons,
but no abnormal subluxation
or dislocation off the median nerve.
So that would be the type of dynamic imaging
that we could take advantage.
When we look at the carpal tunnel.