This page intentionally left blank Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Dr Mike Bradley, FRCR Consultant Radiologist, North Bristol NHS Trust, Honorary Senior Lecturer, University of Bristol Dr Paul O’Donnell, FRCR Consultant Radiologist, Royal National Orthopaedic Hospital, Stanmore, Middlesex, Honorary Senior Lecturer, University College, London CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521728096 © First edition © Cambridge University Press 2002 This edition © M Bradley, P O’Donnell 2010 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2009 ISBN-13 978-0-511-69121-8 eBook (NetLibrary) ISBN-13 978-0-521-72809-6 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use Contents Foreword vii Principles and pitfalls of musculoskeletal ultrasound Echogenicity of tissues xi Chest and neck Supraclavicular fossa TS infraclavicular fossa 11 Sternoclavicular joint 12 Chest wall 13 Axilla 22 Upper limb 26 Shoulder 26 Arm 42 Elbow 49 Forearm 65 Wrist 70 Hand 86 Abdomen and pelvis Anterior wall 98 Posterior wall 109 Groin 112 Pelvis and hip 123 Lower limb Thigh 143 Knee 152 Calf 178 Ankle 187 Foot 206 Index ix 98 143 220 v Foreword The quality of ultrasonic images has seen radical improvement over the last couple of years, and – as can be appreciated in the new edition of this Atlas of Musculoskeletal Ultrasound Anatomy – high frequency applications such as musculoskeletal ultrasound have profited from this development Significant advances in ultrasonic probe design and refined manufacturing techniques have resulted in transducers with outstandingly high bandwidth and sensitivity to provide ultrasonic images with both excellent spatial resolution and penetration at the same time State-of-the-art transducer technology also boosts Doppler performance and supports advanced imaging functions such as trapezoid scan for an extended field of view at no loss of spatial resolution High frequency matrix transducers make use of genuine 4-D imaging technology to achieve finer and more uniform ultrasonic beams in all three dimensions to deliver the most superb and artefact-free images from the very near to the far field Also the dramatic increase of processing power in premium ultrasound systems such as the Aplio XG, with which most of the cases described in this book were acquired, has triggered a quantum leap in image quality Advanced platforms can process the amount of data worth one DVD each second, which allows us to implement the most complex signal processing algorithms to improve image quality, suppress artefacts and extract the desired information from the ultrasonic raw data in real time Uncompromised image quality remains the fundamental merit and to support this in obtaining the fastest and best informed disease management decisions, a variety of powerful imaging functions such as Differential Tissue Harmonics, Advanced Dynamic Flow or Precision Imaging have been developed ApliPureỵ real-time compounding, for example, can simultaneously perform spatial and frequency compounding in transmit and receive to enhance both image clarity and detail definition while preserving clinically significant markers such as shadows behind echo-dense objects These advanced imaging functions work hand in hand with each other to provide the highest resolution and the finest detail Naturally, they can be combined with virtually any other imaging mode such as colour Doppler or 3D/4D for even greater uniformity within each application In spite of all this technical development, we must not forget that the result of an ultrasound scan is highly dependent on the examiner’s skills Only the combination of technological excellence with the dedication and expertise of ultrasound enthusiasts such as the authors of this atlas makes ultrasonic images of outstanding diagnostic value as shown in this book a reality Joerg Schlegel vii Foot Flexor hallucis longus tendon Hyaline cartilage Fat Proximal Distal Proximal phalanx First metatarsal head Plantar plate Fig 4.64 Surface and radiographic anatomy of the flexor hallucis longus LS, probe over first metatarsal head Dynamic examination using flexion/extension of the great toe LS, flexor aspect toe Flexor hallucis longus tendon passes distally between the sesamoid bones and inserts in to the distal phalanx of the great toe 209 Chapter 4: Lower limb Flexor hallucis brevis Origin: medial plantar surface of the cuboid and lateral cuneiform Insertion: splits in two around flexor hallucis longus and inserts either side into the proximal phalanx Each tendon contains a sesamoid bone Flexor hallucis brevis tendon Distal Proximal Medial sesamoid First metatarsal Fig 4.65 Surface and radiographic anatomy of the medial sesamoid LS, probe over medial sesamoid 210 Foot Flexor hallucis longus Lateral Medial Adductor hallucis Lateral sesamoid Metatarsal head Medial sesamoid Fig 4.66 Surface and radiographic anatomy of the sesamoids TS, probe over sesamoids 211 Chapter 4: Lower limb Plantar fascia Attaches proximally to the medial process of the calcaneum and fans into five slips to merge with the flexor digitorum sheaths to attach to the transverse intermetatarsal ligaments and the base of the proximal phalanges Strong septa pass from this fascia laterally to divide flexor digitorum from abductor digiti minimi, and medially from abductor hallucis Fat pad Plantar fascia Medial Lateral Calcaneum Fig 4.67 Surface and radiographic anatomy of the plantar fascia TS, probe over heel pad 212 Foot Fat pad Proximal Plantar fascia Distal Calcaneum Flexor digitorum brevis Fig 4.68 Surface and radiographic anatomy of the plantar fascia LS, probe midline over plantar surface 213 Chapter 4: Lower limb Calcaneum Plantar fascia Proximal Distal Flexor digitorum brevis Fig 4.69 Surface and radiographic anatomy of the plantar fascia LS, panorama plantar fascia 214 Foot Plantar muscles mid foot: four layers Superficial: abductor hallucis, abductor digiti minimi, flexor digitorum brevis Second layer: flexor digitorum longus, quadratus plantae, lumbricals, flexor hallucis longus Third layer: flexor hallucis brevis, flexor digiti minimi, adductor hallucis transversus, adductor hallucis obliquus Fourth layer: interossei, tendons of tibialis posterior and peroneus longus Abductor hallucis Flexor hallucis brevis Medial First metatarsal Flexor digitorum brevis Lateral plantar nerve Flexor digiti minimi Quadratus plantae Lateral Fifth metatarsal Fig 4.70 Surface and radiographic anatomy of the plantar muscles TS, panorama, probe mid foot 215 Chapter 4: Lower limb Dorsum of foot Extensor digitorum longus Tibialis anterior Extensor hallucis longus Lateral Medial Extensor digitorum brevis Talus Extensor digitorum longus Dorsalis pedis Superficial peroneal nerve branch Deep peroneal nerve Extensor hallucis longus Lateral Tibialis anterior Medial Deep peroneal nerve Dorsalis pedis Fig 4.71 Surface and radiographic anatomy of the dorsum of the foot TS, probe over mid dorsum of foot TS, panorama dorsum of foot 216 Foot Lisfranc ligament Ligament from medial cuneiform to second metatarsal base Dorsalis pedis Dorsal band of the lisfranc ligament Medial Lateral Second metatarsal Medial cuneiform Fig 4.72 Surface and radiographic anatomy of the lisfranc ligament TS, probe oblique across cuneiform and second metatarsal 217 Chapter 4: Lower limb Tibialis anterior Distal insertion on the navicular and medial cuneiform with some extension along the medial border of the cuneiform Tibialis anterior Distal Proximal Navicular Medial cuneiform Fig 4.73 Surface and radiographic anatomy of the tibialis anterior insertion LS, probe over medial mid foot 218 Foot Capsule/synovium Extensor hallucis longus tendon Distal Proximal First metatarsal head Extensor hallucis longus Proximal First metatarsal head Proximal phalanx Proximal phalanx Terminal phalanx Distal Fig 4.74 Surface and radiographic anatomy of the extensor hallucis longus LS, probe over dorsum great toe Dynamic examination using flexion/extension of the great toe LS, panorama extensor hallucis tendon 219 Index abdominal wall anterior 98–108 posterior 109–11 abductor digiti minimi 70, 87 abductor pollicis brevis 87 echogenicity xi brachioradialis 49 elbow 49–64 anterior 53–8 lateral 49–52 medial 60 posterior 62–4 calcaneo-fibular ligament 193 adductor canal 151 calf 178–86 antero-lateral compartment 179–80 lateral compartment 181–2 posterior compartment 183–6 adductor longus 134 capsule echogenicity xi extensor carpi ulnaris 79 adductor magnus 134, 137 carpal tunnel 70–3 extensor digiti minimi 79 air echogenicity xi cartilage echogenicity costal cartilage xi fibrocartilage xi hyaline cartilage xi extensor digitorum 79 abductor pollicis longus 79 acromioclavicular joint 26–7 adductor brevis 134 anatomical snuffbox 76–7 anisotropy ix ankle 187–205 anterior 202–5 lateral 193–6 medial 197–201 posterior 187–92 annular ligament 52 anterior cruciate ligament (ACL) 153–7 antero-lateral pelvis 127–30 arm 42–8 anterior 42–7 posterior 48 see also elbow; forearm; wrist axilla 22–5 axillary artery 22, 24 axillary nerve 24 biceps 42, 58–9, 168–9 long head of 28–9 biceps femoris 174 insertion 174 bone echogenicity xi brachial plexus distal proximal 220 brachialis 42 chest wall 13–21 anterior 13 costal cartilages 13–16 lateral 17 posterior 18–21 ribs 13–16 extensor carpi radialis brevis 49, 79 extensor carpi radialis longus 49, 79 extensor digitorum longus 178 extensor hallucis longus 178, 205, 218–19 extensor indicis 79 extensor pollicis brevis 79 extensor pollicis longus 79 extensor retinaculum 202 collateral ligament lateral 167 medial 165 ulnar (UCL) 61 fascia echogenicity xi common extensor origin (CEO) 49 femoral nerve 119 fat echogenicity xi femoral neck 123–4 femoral sheath 113 common flexor origin (CFO) 60 femoral triangle 113–14 common peroneal nerve 171, 176 fibrocartilage echogenicity xi conjoint tendon 114, 117 flexor digiti minimi brevis 87 coracoacromial ligament 36 flexor digitorum longus 183, 199 coracobrachialis 42 flexor hallucis brevis 210 costal cartilages 13–16 echogenicity xi flexor hallicus longus 183, 199, 209 cruciate ligament anterior 153–7 posterior 173 flexor pollicis brevis 87 deep ring 118 foot 206–19 dorsum 216–19 plantar surface 206–15 deltoid ligament 197 flexor retinaculum 70 Index forearm 65–9 anterior 65–7 distal 68 posterior 69 see also wrist latissimus dorsi 18 plantar nerve lateral 199 medial 199 gas echogenicity xi levator scapulae 18 plantaris 183 gastrocnemius 183, 185 ligament echogenicity xi pleura echogenicity xi gluteus maximus 132 linea alba 99 gracilis 134 Lisfranc ligament 217 popliteal fossa 173 cyst space 175 lateral 174–7 greater trochanter 132–3 Lister’s tubercle 79 popliteus 167–8, 174, 183 groin 112–22 femoral triangle 113–14 symphysis pubis 115–18 lower limb see ankle; calf; foot; knee; thigh lumbar triangle 110 Guyon’s canal 70 manubriosternal joint 15 lateral cutaneous nerve of the thigh 120 lateral popliteal fossa 174–7 plantar muscles 215 posterior cruciate ligament 173 quadriceps 143, 145, 152, 155 radial nerve 43 hamstring 140–1, 149 medial collateral ligament 165 rectus abdominis 100, 108 insertion 16, 105–7, 114 hand 86–97 flexor tendons 89–97 palm 86–8 medial meniscus 164 rectus femoris 129–30, 144 medial patellar retinaculum 160 rectus sheath 98, 104 high resolution ultrasound ix median nerve 65, 68 rhomboids 18 hip 123–4 anterior 131 lateral 132–3 medial 134–9 posterior 140–2 metatarsal heads 207 ribs 13–16 movement ix rotator cuff 36 muscle echogenicity xi saphenous nerve 159 nerve echogenicity xi sartorius 127–8, 143 hyaline cartilage echogenicity xi oblique muscles 102, 103 ilio-inguinal nerve 122 obturator nerve 139 ilio-hypogastric nerve 103, 121 opponens digiti minimi 87 scalene muscles 2–10 scalenus anterior scalenus medius scalenus posterior ilio-psoas 125–6 opponens pollicis 87 sciatic nerve 142, 149–50 ilio-tibial tract 170–2 palm 86–8 semi-membranosus 161–3 inferior epigastric vessels 116 palpation ix serratus anterior 17 infraclavicular fossa 10–11 paratenon 192 echogenicity xi sesamoids 210–11 infraspinatus 32–8 inguinal canal 112 inguinal ligament 112 intercostal muscles 13, 17, 21 interosseous scapholunate ligament 85 jugular vein knee 152–77 anterior 152–6 antero-medial 159–60 lateral 167–9 medial 164–6 posterior 173 lateral collateral ligament 167 patella tendon 152–4 pectineus 134 pelvis 127–30 periosteum echogenicity xi peroneal nerve 172 common 171, 176 superficial 180 shoulder 26–41 acromioclavicular joint 26–7 infraspinatus 32–8 long head of biceps 28–9 posterior joint 39–41 subscapularis 28–31 supraspinatus 32–6 soleus 183 peroneus brevis 181, 195–6 sternoclavicular joint 12 peroneus longus 181, 195–6 sternomastoid peroneus tertius 178 subscapularis 22, 28–31 pes anserinus 159–63 superficial ring 117 plantar fascia 212–14 supraclavicular fossa 1–10 221 Index supraspinatus 32–6 thoracolumbar fascia 109 trochlear groove 158 symmetry ix thumb carpometacarpal joint 78 ulnar artery 70 symphysis pubis 107, 115–18 synovium echogenicity xi talo-fibular ligament 194–3 222 tibial nerve 176 posterior 199 ulnar collateral ligament (UCL) 61 ulnar nerve 62, 64, 70 tarsal tunnel 199 tibialis anterior 178, 180, 203–4, 218 upper limb see arm; elbow; forearm; hand; wrist wrist 70–85 anterior 70–3 lateral 70–8 posterior 79–85 tendo-achilles 187–91 tibialis posterior 183, 199, 201 tendon echogenicity xi tibio-navicular ligament 198 teres minor 39 trapezius 18 thigh 143–51 anterior 143–8 posterior 149–50 triceps 48 trochanteric bursa 132 xiphisternum 105 ... improvement over the last couple of years, and – as can be appreciated in the new edition of this Atlas of Musculoskeletal Ultrasound Anatomy – high frequency applications such as musculoskeletal ultrasound. ..This page intentionally left blank Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Dr Mike Bradley, FRCR Consultant... compound imaging Anatomy – knowledge of the relevant anatomy is essential for accurate diagnosis and location of disease Symmetry – The sonographer can often compare anatomical areas for symmetry