(BQ) Part 2 book Fundamentals of musculoskeletal ultrasound presents the following contents: Hip and thigh ultrasound, knee ultrasound, ankle, foot and lower leg ultrasound, interventional techniques.
C H A P T E R â•… Hip and Thigh Ultrasound CHAPTER OUTLINE HIP AND THIGH ANATOMY ULTRASOUND EXAMINATION TECHNIQUE General Comments Hip Evaluation: Anterior Hip Evaluation: Lateral Hip Evaluation: Posterior Inguinal Region Evaluation Thigh Evaluation: Anterior Thigh Evaluation: Medial Thigh Evaluation: Posterior Hip Evaluation for Dysplasia in a Child JOINT AND BURSAL ABNORMALITIES Joint Effusion and Synovial Hypertrophy Labrum and Proximal Femur Abnormalities Additional videos for this topic are available online at www.expertconsult.com HIP AND THIGH ANATOMY The hip joint is a synovial articulation between the acetabulum of the pelvis and the proximal femur The joint recess extends from the acetabulum over the femur to the level of the intertrochanteric line, just beyond the femoral neck The joint capsule becomes thickened from the iliofemoral, ischiofemoral, and pubofemoral ligaments (Fig 6-1A) and a reflection of the joint capsule extends proximally along the femoral neck.1 The femoral head is covered by hyaline cartilage, whereas the acetabulum is lined by hyaline cartilage in an inverted U shape with a fibrocartilage labrum attached to the acetabular rim 162 Bursal Abnormalities Postsurgical Hip TENDON AND MUSCLE ABNORMALITIES Tendon and Muscle Injury Snapping Hip Syndrome Calcific Tendinosis Diabetic Muscle Infarction Pseudohypertrophy of the Tensor Fasciae Latae PERIPHERAL NERVE ABNORMALITIES MISCELLANEOUS CONDITIONS Morel-Lavallée Lesion Inguinal Lymph Node Other Soft Tissue Masses Hernias Developmental Dysplasia of the Hip Several muscles originate from the pelvis and extend across the hip joint, and others originate from the femur itself (see Fig 6-1B and C) Muscles that originate from the posterior surface of the ilium are the gluteus minimus (which inserts on the anterior facet of the greater trochanter), the gluteus medius (which inserts on the lateral and superoposterior facets of the greater trochanter), and the gluteus maximus (which inserts on the posterior femur gluteal tuberosity below the trochanters and iliotibial tract).2 Posteriorly, the piriformis originates from the sacrum and extends inferior and lateral to insert onto the greater trochanter Other muscles inferior to the piriformis that extend from the ischium to the proximal femur include the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris At the anterior aspect of the hip joint, the iliopsoas can be seen as a continuation of the iliacus and psoas muscles, which inserts on 6â•… Hip and Thigh Ultrasound the lesser trochanter Other anterior muscles include the sartorius (which originates from the anterior superior iliac spine of the pelvis and inserts on the medial aspect of the proximal tibia) and the tensor fasciae latae (which originates from the posterolateral aspect of the ilium and inserts on the iliotibial tract, which, in turn, inserts on the proximal tibia) The rectus femoris has two origins: a direct or straight head, which originates from the anterior inferior iliac spine; and an indirect or reflected head, which originates inferior and posterior to the anterior inferior iliac spine from the superior acetabular ridge.3 Distally, the direct tendon forms an anterior superficial tendon with unipennate architecture, whereas the indirect tendon forms the central tendon with bipennate architecture.4 The rectus femoris distally combines with the vastus medialis, vastus lateralis, and vastus intermedius musculature (which all originate from the femur) to form the quadriceps tendon, which inserts on the patella and, to a lesser extent, the tibial tuberosity by way of the patellar tendon Medially, the adductor musculature includes the adductor longus, the adductor brevis, and the adductor magnus, which originate from the ischium and pubis of the pelvis and insert on the femur at the linea aspera and, in the case of the adductor magnus, the adductor tubercle as well Superficial and medial to the adductors, the 163 gracilis muscle extends from the inferior pubic ramus to the proximal tibia as part of the pes anserinus From medially to laterally, the posterior thigh consists of the semimembranosus, the semitendinosus (both of which originate from the ischial tuberosity and insert on the proximal tibia, with the semitendinosus being part of the pes anserinus), and the biceps femoris (with long head origin from the ischial tuberosity and short head origin from the femur; the biceps femoris inserts on the fibula and lateral tibial condyle) Proximally, the semimembranosus tendon is located anterior to the conjoint tendon of the biceps femoris long head and semitendinosus and the semitendinosus muscle belly; the semimembranosus origin on the ischium is anterolateral to the conjoint tendon origin.5 Other important structures of the anterior thigh include (medial to lateral) the femoral nerve, artery, and vein (use the mnemonic NAVEL for nerve, artery, vein, empty space, lymphatic) The sciatic nerve is seen posteriorly adjacent to the biceps femoris muscle, where it bifurcates as the tibial nerve and the common peroneal nerve laterally Several bursae are located around the hip joint The iliopsoas bursa is located anteriorly along the medial aspect of the iliopsoas tendon, has a convex lateral shape, and normally communicates with the hip joint in up to 15% of the population.6 The trochanteric Anterior inferior iliac spine Iliopubic eminence Pubofemoral ligament Iliofemoral ligament Ischiofemoral ligament A FIGURE 6-1╇ ╇ Hip and thigh anatomy A, Anterior and posterior views show the hip joint ligaments Continued 164 Fundamentals of Musculoskeletal Ultrasound Sartorius Reflected head of rectus femoris Straight head of rectus femoris Vastus medialis Vastus lateralis Vastus lateralis Vastus intermedius Medial compartment of thigh Posterior compartment of thigh Rectus femoris Vastus lateralis Vastus intermedius Sartorius Rectus femoris Vastus medialis Adductor canal Vastus medialis Sartorius Articularis genus Suprapatellar bursa Quadriceps femoris tendon Quadriceps femoris tendon Patella Patellar ligament Patellar ligament Pes anserinus Tibial tuberosity Attachment of pes anserinus B Sartorius Gracilis Semitendinosus FIGURE 6-1, cont’d╇ ╇ B, Muscles of the anterior thigh compartment (or subgluteus maximus) bursa is located posterolateral over the posterior and lateral facets of the greater trochanter deep to the gluteus maximus and iliotibial tract, whereas smaller subgluteus medius and subgluteus minimus bursae are located between the lateral facet and gluteus medius and the anterior facet and gluteus minimus, respectively.2 Other possible bursae include the obturator externus bursa, located medially and inferior to the femoral neck, which may communicate with the posteroinferior hip joint.7 In the inguinal region, the inguinal canal represents a triangular, elongated passage in the lower abdominal wall located just superior to the inguinal ligament (see Fig 6-1D) The inguinal canal’s posterior opening, the deep inguinal ring, is located laterally, whereas the anterior opening, 6â•… Hip and Thigh Ultrasound 165 Ischial tuberosity Quadratus femoris Adductor magnus Long head of biceps femoris Hamstring part of adductor magnus Semitendinosus Semimembranosus Short head of biceps femoris Part of semimembranosus that inserts into capsule around knee joint C On anterior aspect of tibia attaches to pes anserinus FIGURE 6-1, cont’d╇ ╇ C, Muscles of the posterior thigh compartment Continued called the superficial inguinal ring, is located medially near the pubis The contents of the inguinal canal include the ilioinguinal nerve and the spermatic cord in males and the round ligament in females The deep inguinal ring is located just lateral to the origin of the inferior epigastric artery from the external iliac artery The inguinal (or Hesselbach) triangle is demarcated by the lateral margin of the rectus abdominis medially, the inguinal ligament inferiorly, and the superior epigastric artery laterally.8 Another structure near the inguinal ligament is the lateral femoral cutaneous nerve This peripheral nerve exits the pelvis to extend over the lateral thigh in a somewhat variable manner—it may course across the iliac crest, within the sartorius tendon, within the inguinal ligament, or under the inguinal ligament.9 The lateral femoral cutaneous nerve may also branch proximal to the inguinal ligament 166 Fundamentals of Musculoskeletal Ultrasound R H C L D FIGURE 6-1, cont’d╇ ╇ D, Illustration of the male right inguinal region as viewed from within the abdomen shows the inferior epigastric artery (arrow), deep inguinal ring (open arrow), vas deferens (arrowhead), inguinal ligament (curved arrow), Hesselbach triangle (H), conjoint tendon (C), lacunar ligament (L), rectus abdominis (R), and location of femoral hernia (asterisk) (A to C, From Drake R, Vogl W, Mitchell A: Gray’s anatomy for students, Philadelphia, 2005, Churchill Livingstone; D, from Jamadar DA, Jacobson JA, Morag Y, et╯al: Sonography of inguinal region hernias AJR Am J Roentgenol 187:185–190, 2006.) ULTRASOUND EXAMINATION TECHNIQUE Table 6-1 is a checklist for hip and thigh ultrasound examination Examples of diagnostic hip ultrasound reports are available online at www expertconsult.com (see eBox 6-1 and 6-2) General Comments Ultrasound examination of the hip and anterior thigh is completed with the patient supine; the patient is prone for evaluation of the posterior thigh For evaluation of the greater trochanteric region, the patient rolls on the contralateral side Evaluation of the hip and thigh may be considered as two separate examinations in most circumstances Hip pain in an athlete may be caused from hip joint disease, tendon or muscle pathology, or adjacent hernia, and therefore all etiologies should be considered The choice of transducer frequency depends on the patient’s body habitus, although many times the anterior hip can be evaluated with a transducer greater than 10╯MHz With large amounts of soft tissue, a transducer of less than 10╯MHz may be needed to penetrate the soft tissues adequately It is important to consider these lower frequencies initially regardless of body habitus because one should examine the entire depth of the soft TABLE 6-1â•… Hip and Thigh Ultrasound Examination Checklist Location Structures of Interest Hip: anterior Hip: lateral Hip: posterior Inguinal region Thigh: anterior Thigh: medial Thigh: posterior Hip joint, iliopsoas, rectus femoris, sartorius, pubic symphysis Greater trochanter, bursae Sacroiliac joints, piriformis, hip abductors Deep inguinal ring, Hesselbach triangle, femoral artery region Rectus femoris, vastus medialis, vastus intermedius, vastus lateralis Femoral artery and nerve, sartorius, gracilis, adductors Semimembranosus, semitendinosus, biceps femoris, sciatic nerve tissues before focusing on the more superficial structures This approach ensures a complete and global evaluation and also serves to orient the examiner to the various muscles, an important consideration because the bone landmarks are few and deep One may also consider a curvilinear transducer or a virtual convex function with a linear transducer (if present) to accomplish this Evaluation of the hip and thigh may be focused over the area that is clinically symptomatic or relevant to the patient’s history Regardless, a 6â•… Hip and Thigh Ultrasound complete examination of all areas should always be considered for one to become familiar with normal anatomy and normal variants and to develop a quick and efficient sonographic technique Hip Evaluation: Anterior The primary structures evaluated include the hip joint and recess, iliopsoas tendon and bursa, proximal thigh musculature origin in the hip region (rectus femoris and sartorius), and pubic symphysis region Depending on patient history and symptoms, all of these structures should be considered in the evaluation because symptoms may be referred and etiology multifactorial Evaluation begins with the anterior hip with the transducer long axis to the femoral neck, which is in 167 the oblique-sagittal plane (Fig 6-2A) To find the femoral neck, one may initially image transversely over the femoral shaft to locate the curved and echogenic surface of the femur and then move the transducer proximally; once the bony protuberances of the greater and lesser trochanter are identified, the transducer is turned to the sagittaloblique plane parallel to the femoral neck The hip joint may also be located lateral to the femoral vasculature The hip joint is identified long axis to the femoral neck by the characteristic bone contours of the femoral head, acetabulum, and femoral neck (see Fig 6-2B to D) It is at this location superficial to the femoral neck where the anterior joint recess is evaluated for fluid or synovial abnormalities.1 The anterior recess of the hip joint over the femoral neck is normally about to 6╯mm thick, I H A N A B I I A H H D N C FIGURE 6-2╇ ╇ Hip joint evaluation (long axis) A, Sagittal-oblique imaging over the proximal femur shows (B to D) the femoral head (H), femoral neck (N), and collapsed anterior joint recess (arrowheads) Note the acetabulum (A) and fibrocartilage labrum (arrows) I, iliopsoas 168 Fundamentals of Musculoskeletal Ultrasound and this can be explained anatomically.1 The anterior joint capsule extends inferiorly from the labrum and inserts at the intertrochanteric line; however, some fibers are reflected superiorly along the femoral neck to attach at the femoral head-neck junction (Fig 6-3) Both the anterior and posterior layers measure to 3╯mm each in thickness; physiologic fluid between these layers should measure less than 2╯mm, and typically no fluid is identified in the normal situation.1 The anterior capsule layer may be slightly thicker than the posterior layer as a result of capsular thickening from ligaments and the zona orbicularis, which encircles the capsule at the femoral headneck junction The posterior layer may demonstrate focal thickening at its attachment at the femoral head-neck junction The normal anterior joint recess is usually concave or flat anteriorly, rather than convex The true hyperechoic and fibrillar appearance of the joint capsule and its reflection is best appreciated when the femoral neck is perpendicular to the sound beam (see Fig 6-2C); if imaged obliquely, the joint capsule may artifactually appear hypoechoic and may simulate fluid in echogenicity, especially in a patient with a large body habitus (see Fig 6-2B) The femoral head and neck should be smooth, and the visualized portion of the hypoechoic hyaline cartilage that covers the femoral head should be uniform The fibrocartilage labrum is hyperechoic and A H N B FIGURE 6-3╇ ╇ Anterior hip joint recess A, A sagittaloblique illustration through the femoral head and neck and (B) an ultrasound image show the anterior layer of the joint capsule (arrows) and the posterior layer (arrowheads) H, femoral head; N, femoral neck) (Modified from an illustration by Carolyn Nowak, Ann Arbor, Mich http://www.carolyncnowak.com/MedTech.html.) triangular and extends from the margins of the acetabulum (see Fig 6-2D) The femoral head and neck are also evaluated in short axis to the femoral neck (Fig 6-4) To evaluate the iliopsoas region, the transducer is first placed in the transverse plane over the femoral head because this bone landmark is easy to identify (see Fig 6-4B) The transducer is then moved superiorly and angled parallel to the inguinal ligament (Fig 6-5) The characteristic bone contours are seen along with the iliopsoas muscle and tendon, the rectus femoris origin at the anterior inferior iliac spine, and the external iliac vessels As with imaging any tendon in short axis, toggling the transducer is often helpful to visualize the tendon as hyperechoic, especially because the iliopsoas normally courses deep toward the lesser trochanter and is oblique to the sound beam The iliopsoas should be evaluated dynamically for tendon snapping (see Snapping Hip Syndrome later in the chapter) The anterior hip is also evaluated for iliopsoas bursa, which originates at the level of the femoral head and typically extends medial and possibly deep to the iliopsoas tendon The transducer is also rotated 90 degrees to evaluate the iliopsoas tendon in long axis (see Fig 6-2) To further evaluate the rectus femoris origin, the transducer is positioned over the anterior inferior iliac spine in the transverse plane The direct head is seen directly superficial to the anterior inferior iliac spine, whereas the indirect head is at the lateral aspect of the acetabulum (Fig 6-6) When evaluating the direct head in long axis (see Fig 6-6B), moving the transducer slightly laterally will show the indirect head coursing proximal and deep, appearing hypoechoic from anisotropy, and producing a characteristic refraction shadow (see Fig 6-6C) (Video 6-1) The transducer can be rotated in plane with the indirect head and moved over the lateral hip to identify the origin of the indirect head without artifact (see Fig 6-6D) (Video 6-2) The transducer is then returned to short axis relative to the rectus femoris direct head and moved proximally and laterally to visualize the sartorius and its origin on the anterior superior iliac spine (Fig 6-7) Evaluation for the lateral femoral cutaneous nerve begins with the transducer in the transverse plane over the proximal sartorius near the anterior superior iliac spine.10 As the transducer is moved distally, the lateral femoral cutaneous nerve can be seen as several nerve fascicles coursing over the sartorius from medial to lateral (Fig 6-8A) More distally, the lateral femoral cutaneous nerve is identified in a triangular hypoechoic fatty space at the lateral aspect of the sartorius (see Fig 6-8B) (Video 6-3).11 The transducer is 6â•… Hip and Thigh Ultrasound 169 I H A B A H C FIGURE 6-4╇ ╇ Hip joint evaluation (short axis) A, Transverse-oblique imaging shows (B) the anterior layer of the joint capsule and iliofemoral ligament (arrowheads) with hypoechoic hyaline cartilage over the femoral head (H) C, Ultrasound image at the proximal aspect of the femoral head (H) shows the iliopsoas muscle (arrowheads) and tendon (curved arrow) A, acetabulum; I, iliopsoas A I E B A FIGURE 6-5╇ ╇ Iliopsoas evaluation (short axis) A, Transverse-oblique imaging shows (B) the iliopsoas tendon (curved arrow) and muscle (arrowheads), rectus femoris direct head (arrow), femoral artery (A), and femoral nerve (open arrow) E, iliopectineal eminence; I, anterior inferior iliac spine 170 Fundamentals of Musculoskeletal Ultrasound S T MED I MIN I A B A C D FIGURE 6-6╇ ╇ Rectus femoris origin evaluation A, Transverse imaging over the anterosuperior iliac spine (I) shows the direct head (arrowheads) and indirect head (arrows) (left side of image is lateral) B, Ultrasound image in sagittal plane shows the direct head of the rectus femoris in long axis (arrowheads) C, Ultrasound image moving lateral to (B) shows refraction shadow (open arrows) from the indirect head of the rectus femoris and anisotropy D, Ultrasound image in the coronal-oblique plane over the lateral acetabulum (A) shows the indirect head of the rectus femoris in long axis (arrows) MED, gluteus medius; MIN, gluteus minimus; S, sartorius; T, tensor fasciae latae S T IL R I I A B FIGURE 6-7╇ ╇ Sartorius evaluation Ultrasound images show the (A) short axis and (B) long axis of the sartorius (S and arrows) I, iliopsoas; IL, ilium; R, rectus femoris; T, tensor fascia latae 6â•… Hip and Thigh Ultrasound 171 S S I I T R A C S T R B D FIGURE 6-8╇ ╇ Lateral femoral cutaneous nerve evaluation A, Ultrasound image in short axis to the sartorius (S) shows nerve fascicles (arrows) B, More distally, one nerve fascicle (arrow) is within hypoechoic fat C, Proximal view at the level of the inguinal ligament (arrowheads) shows nerve fascicles (arrows) in short axis and (D)) long axis I, iliacus; R, rectus femoris; T, tensor fascia latae then moved proximally to evaluate for potential nerve entrapment at the inguinal ligament (see Fig 6-8C and D).12 The lateral femoral cutaneous nerve may branch proximal to the inguinal ligament and has a variable course; it may cross over the iliac crest, through the sartorius tendon, through the inguinal ligament, or under the inguinal ligament.9 Although thigh evaluation is considered separately, patients with hip pain (especially sportsrelated pain) may have abnormalities at the adductor tendon origin and the rectus abdominis insertion, with possible abnormalities directly associated with the pubic symphysis.13 The transducer is placed in midline over the pubic symphysis, identified by its characteristic bone contours (Fig 6-9A) The transducer is turned 90 degrees to evaluate the rectus abdominis in long axis and then rotated toward the adductors to evaluate the common aponeurosis and adductor tendon origin (see Fig 6-9B) Hip Evaluation: Lateral To evaluate the soft tissues over the greater trochanter, bone landmarks are essential (Fig 6-10) The patient rolls toward the opposite hip to access the posterolateral region of the hip and the transducer is placed over the lateral hip (Fig 6-11A) To locate the greater trochanter, one R R R P P A A P B FIGURE 6-9╇ ╇ Pubic symphysis and common aponeurosis A, Ultrasound image transverse in midline shows distal rectus abdominis muscles (R) and pubic symphysis (open arrow) B, Ultrasound image in the sagittal-oblique plane shows common aponeurosis (open arrows) over the pubis (P) between the rectus abdominis (R) and adductor musculature (A) REFERENCES Joines MM, Motamedi K, Seeger LL, et al: MusculoÂ� skeletal interventional ultrasound Semin Musculoskelet Radiol 11:192–198, 2007 Adler RS, Sofka CM: Percutaneous ultrasound-guided injections in the musculoskeletal system Ultrasound Q 19:3–12, 2003 Daley EL, Bajaj S, Bisson LJ, et al: Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? 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A retrospective study of 47 cases Clin J Sport Med 20:488–490, 2010 42 Housner JA, Jacobson JA, Misko R: Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis J Ultrasound Med 28:1187–1192, 2009 43 Chiou HJ, Chou YH, Wu JJ, et al: Alternative and effective treatment of shoulder ganglion cyst: ultrasonographically guided aspiration J Ultrasound Med 18:531–535, 1999 Sample Interventional Ultrasound Report eBOX 9-1 Examination: Ultrasound-Guided Injection of Right Biceps Brachii Long Head Tendon Sheath Date of Study: March 11, 2011 Patient Name: Jack White Registration Number: 8675309 History: Pain Findings: Limited ultrasound over the anterior right shoulder demonstrates minimal joint fluid distending the biceps brachii long head tendon sheath No evidence for hyperemia or synovial hypertrophy to suggest tenosynovitis No evidence for biceps brachii long head tendon tear No tendon subluxation or dislocation with dynamic imaging No abnormal subacromial-subdeltoid bursal thickening After obtaining both written and verbal informed consent discussing potential risks (bleeding, infection, soft tissue injury) and benefits, using sterile technique and local anesthetic injection (provide type and amount), a 20gauge spinal needle with stylet was inserted into the long head of the biceps brachii tendon sheath Intrasheath location of needle tip was confirmed with a small amount of anesthetic injection This was followed by corticosteroid injection (provide type and amount) The patient tolerated the procedure well without complications The patient’s pain level changed from 8/10 before procedure to 2/10 Impression: Limited diagnostic ultrasound of the anterior shoulder showed minimal joint fluid Successful long head biceps brachii tendon sheath corticosteroid injection with pain relief as noted above and without complications 44 Breidahl WH, Adler RS: Ultrasound-guided injection of ganglia with corticosteroids Skeletal Radiol 25:635–638, 1996 45 Smith J, Wisniewski SJ, Finnoff JT, et al: Sonographically guided carpal tunnel injections: the ulnar approach J Ultrasound Med 27:1485–1490, 2008 46 Gogna A, Peh WC, Munk PL: Image-guided musculoskeletal biopsy Radiol Clin North Am 46:455–473, v, 2008 47 Peer S, Freuis T, Loizides A, et al: Ultrasound guided core needle biopsy of soft tissue tumors: a fool proof technique? Med Ultrason 13:187–194, 2011 48 Vasilevska V, Gligorievski A, Zafiroski G, et al: Radiologicpathologic correlation of 100 consecutive biopsied soft tissue musculoskeletal lesions after multimodality imaging Cancer Imaging 11:S42, 2011 eBOX 9-2 Sample Interventional Ultrasound Report Examination: Ultrasound-Guided Right Iliopsoas Peritendon Injection Date of Study: March 11, 2011 Patient Name: Jack White Registration Number: 8675309 History: Pain, evaluate for tendon tear Findings: Limited ultrasound over the anterior right hip showed no hip joint effusion and unremarkable anterior hip labrum The rectus femoris was normal No evidence for iliopsoas bursal distention Dynamic imaging showed no evidence for snapping iliopsoas tendon After obtaining both written and verbal informed consent discussing potential risks (bleeding, infection, soft tissue injury) and benefits, using sterile technique and local anesthetic injection (provide type and amount), a 20-gauge spinal needle with stylet was directed between the iliopsoas tendon and ilium superior to the femoral head Needle tip location between the iliopsoas tendon and ilium was confirmed with a small amount of anesthetic injection This was followed by corticosteroid injection (provide type and amount) The patient tolerated the procedure well without complications The patient’s pain level changed from 8/10 before procedure to 2/10 Impression: Limited diagnostic ultrasound of the anterior right hip showed no abnormality Successful right iliopsoas peritendon corticosteroid injection with pain relief as noted above and without complications APPENDIX Examination Checklists Shoulder Ultrasound Examination Checklist Step Structures/Pathologic Features of Interest Biceps brachii long head Subscapularis, biceps tendon dislocation Supraspinatus, infraspinatus Acromioclavicular joint, subacromialsubdeltoid bursa, dynamic evaluation Posterior glenohumeral joint, labrum, teres minor, infraspinatus Wrist and Hand Ultrasound Examination Checklist Location Volar (no 1) Volar (no 2) Volar (no 3) Dorsal (no 1) Dorsal (no 2) Dorsal (no 3) Structures of Interest/Pathologic Features Median nerve Flexor tendons Volar joint recesses Scaphoid Flexor carpi radialis Volar ganglion cyst Ulnar nerve and artery Extensor tendons Dorsal joint recesses Scapholunate ligament Dorsal ganglion cyst Triangular firbrocartilage complex Elbow Ultrasound Examination Checklist Finger Ultrasound Examination Checklist Location Structures of Interest Location Structures of Interest Anterior Brachialis Biceps brachii Median nerve Anterior joint recess Ulnar collateral ligament Common flexor tendon and pronator teres Ulnar nerve Common extensor tendon Radial collateral ligament complex Radial head and annular recess Capitellum Radial nerve Posterior joint recess Triceps brachii Olecranon bursa Volar Flexor tendons Pulleys Volar plate Joint recesses Extensor tendon Joint recesses Collateral ligaments Medial Lateral Posterior 370 Dorsal Other â•… Examination Checklists 371 Hip and Thigh Ultrasound Examination Checklist Ankle, Calf, and Forefoot Ultrasound Examination Checklist Location Structures of Interest Location Structures of Interest Hip: anterior Hip: lateral Hip: posterior Inguinal region Thigh: anterior Thigh: medial Thigh: posterior Hip joint, iliopsoas, rectus femoris, sartorius, pubic symphysis Greater trochanter, bursae Sacroiliac joints, piriformis, hip abductors Deep inguinal ring, Hesselbach triangle, femoral artery region Rectus femoris, vastus medialis, vastus intermedius, vastus lateralis Femoral artery and nerve, sartorius, gracilis, adductors Semimembranosus, semitendinosus, biceps femoris, sciatic nerve Ankle: anterior Anterior tibiotalar joint recess Tibialis anterior Extensor hallucis longus Dorsal pedis artery Superficial peroneal nerve Extensor digitorum longus Tibialis posterior Flexor digitorum longus Tibial nerve Flexor hallucis longus Deltoid ligament Peroneus longus and brevis Anterior talofibular ligament Calcaneofibular ligament Anterior tibiofibular ligament Achilles tendon Posterior bursae Plantar fascia Soleus Medial and lateral heads of gastrocnemius Plantaris Achilles tendon Dorsal joint recesses Morton neuroma Ankle: medial Ankle: lateral Ankle: posterior Knee Ultrasound Examination Checklist Structures/ Pathologic Features Anterior Medial Lateral Posterior Location of Interest Quadriceps tendon Patella Patellar tendon Patellar retinaculum Suprapatellar recess Medial and lateral recesses Anterior knee bursae Femoral articular cartilage Medial collateral ligament Medial meniscus: body and anterior horn Pes anserinus Iliotibial tract Lateral collateral ligament Biceps femoris Common peroneal nerve Popliteus Lateral meniscus: body and anterior horn Baker cyst Menisci: posterior horns Posterior cruciate ligament Anterior cruciate ligament Neurovascular structures Calf Forefoot This page intentionally left blank Index Page numbers followed by “f” indicate figures, “t” indicates tables, and “e” indicates supplemental online material A Achilles tendon, 275–277, 277f abnormalities, 317, 318f–319f repair, 316–317, 318f tears, 317e full-thickness, 316–317, 316f–317f partial-thickness, 315, 315f tendinosis, 308–315, 312f–314f ACL See Anterior cruciate ligament Acromioclavicular joint, 64–66, 66f infection, 67f injury, 67f procedures, 346f–347f shoulder ultrasound examination technique, 15–16, 16f–17f Adductor insertion avulsion syndrome, 193–195, 196f Adductor pollicis aponeurosis, 150–151, 151f Adhesive capsulitis, 42–44, 44f Adventitious bursae, 291–293, 292f Amputation neuroma, shoulder, 69, 70f Angioleiomyoma, 158, 159f Anisotropy, 1e6–1e7, 1e7f–1e8f Ankle anatomy, 257–264 ligamentous, 263–264 muscle, 257–263 tendon, 257–263 bursal abnormalities, 279–293, 291f, 293f adventitious, 291–293, 292f cysts, 335–337, 336f–337f ganglion, 335–336, 336f fractures, 327–332, 331f–332f giant cell tumor, 335, 336f Haglund syndrome, 291, 292f high ankle sprain, 323 inflammatory arthritis, 285–291 gout, 287–289, 288f–290f psoriatic arthritis, 289–291, 290f rheumatoid arthritis, 285–287, 285f–288f interosseous membrane, 275, 276f joint abnormalities, 279–293 joint effusion, 279–285, 281f, 283f joint procedures, 352–355, 353f–354f knot of Henry, 259–260, 267–268, 270f ligaments abnormalities of, 323–327, 329f–331f anatomy, 263–264 Ankle (Continued) Bassett, 263–264 lateral, 274, 274f, 315f, 325f–327f lower leg, 291–293, 291f, 293f masses, 335–337, 336f–337f muscle abnormalities, 293–323 anterior, 307–308, 311f lateral, 300–306 medial, 293–300, 294f–296f osseous anatomy, 257, 258f–263f peripheral nerve abnormalities, 332–335, 333f–335f peroneal tendons, 271–274, 272f–273f abnormalities, 302–304, 303f–304f sinus tarsi, 257 synovial hypertrophy, 279–285, 282f, 284f–285f tendinosis, 295, 297f lateral, 301–302, 301f–302f tendon abnormalities, 293–323 anterior, 307–308, 309f–311f lateral, 300–306, 301f, 303f, 305f–308f medial, 293–300, 294f–295f, 300f peroneal, 302–304, 303f–304f posterior, 308–317, 312f–314f repair of, 316–317, 318f tendon tears, 315, 315f–317f full-thickness, 298–300, 299f–300f partial-thickness, 295–298, 297f–299f ultrasound, 257–337 anterior evaluation, 264–266, 265f–266f examination technique for, 264–279 general comments on, 264 lateral evaluation, 269–275, 271f–272f, 275f medial evaluation, 266–269, 267f–271f posterior evaluation, 275–278 ultrasound examination checklist, 371t ultrasound report, 337e Anterior cruciate ligament (ACL), 237–240, 240f Arthritis, inflammatory, 285–291 gout, 287–289, 288f–290f ankle, 287–289, 288f–290f foot, 287–289, 288f–290f Arthritis, inflammatory (Continued) hand, 134–135, 135f–136f knee, 240–242, 241f–242f lower leg, 287–289, 288f–290f wrist, 134–135, 135f–136f psoriatic, 289–291, 290f rheumatoid, 285–287, 285f–288f Arthritis, pathology, 2e12–2e16 gout, 2e15, 2e15f–2e16f osteoarthritis, 2e15–2e16, 2e16f psoriatic, 2e14–2e15, 2e14f rheumatoid, 2e12–2e14, 2e13f–2e14f Avulsion adductor insertion, 193–195, 196f subscapularis tendon, 34f B Baker cyst, 212, 223–224, 244–247, 246f–247f bursal procedures, 357, 358f–359f Bassett ligament, 263–264 Beam-width artifact, 1e9 Biceps brachii tendon abnormalities, 93–96, 94f–96f long head of shoulder ultrasound examination technique and, 5–6, 6f–7f tendon sheath procedures, 358, 360f Biceps tendon, 49–56 dislocation, 52–56, 55f–56f shoulder ultrasound examination technique and, 7–8, 8f–9f ganglion cyst, 51–52, 53f intra-articular body, 49–51, 51f joint effusion, 49–51, 50f–51f subluxation, 52–56, 54f tears, 51–52, 52f–53f tendinosis, 51–52, 52f, 54f tenosynovitis, 49–51, 50f Biopsy, 368–369, 369f lymph node, 368–369, 369f soft tissue mass, 368–369, 369f synovial, 344–345 Bone abnormalities, knee, 242–244 proliferation, hand and wrist, 134, 134f–135f Bone injury, pathology, 2e6–2e8 types and, 2e7, 2e7f Bone masses, pathology, 2e33–2e35, 2e34f–2e35f, 2e36f–2e37f Bowstringing, 143 Boxer knuckle, 140, 142f 373 374 Index Bursae adventitious, 291–293, 292f greater trochanteric, procedures, 356–357, 357f iliopsoas, 356, 356f intermetatarsal, 291–293 knee, 244–249, 248f–251f olecranon, 90–93, 92f–93f subacromial-subdeltoid, 56–57, 57f–60f procedures, 355–356, 355f–356f shoulder ultrasound examination technique, 15–16, 16f–17f simulating tendon, 47–48, 47f–48f Bursal abnormalities ankle, 279–293 elbow, 85–93, 92f–93f foot, 279–293, 291f, 293f hip and thigh, 181–192, 189f–191f lower leg, 279–293, 291f, 293f olecranon bursa, 90–93, 92f–93f Bursal fluid, supraspinatus tendon, 31, 32f Bursal procedures, 355–357, 359f Baker cyst, 357, 358f–359f greater trochanteric bursae, 356–357, 357f iliopsoas bursa, 356, 356f subacromial-subdeltoid bursa, 355–356 C Calcific tendinosis, 38–40, 41f–42f lavage and aspiration, 362–364, 363f–364f Calf muscle abnormalities, 317–321, 319f–322f tendon abnormalities, 317–321, 319f–322f ultrasound evaluation, 278, 279f ultrasound examination checklist, 371t Carpal tunnel syndrome, 144–146, 145f–147f Cartilage abnormalities, knee, 231–236, 233f, 235f–236f interface sign, supraspinatus tendon, 32 sonographic appearances of normal, 1e5–1e6, 1e5f triangular fibrocartilage, 110 complex, wrist, 124, 125f Children, hip evaluation for dysplasia in, 180–181, 180e–181e Collateral ligaments lateral, abnormalities, 242–244, 243f medial, abnormalities, 242, 243f tibial, sonographic appearances of normal, 1e5–1e6, 1e6f ulnar, injury, 149–151, 150f–151f Crass position, 8–9, 12f Cruciate ligaments abnormalities, 244, 244f–245f ACL, 237–240, 240f Cysts ankle, 335–337, 336f–337f aspiration, 367–368, 367f–368f Baker, 212, 223–224, 244–247, 246f–247f bursal procedures, 357, 358f–359f dorsal ganglion, 123 foot, 335–337, 336f–337f ganglion aspiration, 367–368, 367f–368f dorsal, wrist, 123 foot and ankle, 335–336, 336f hand and wrist, 154–157, 156f–157f knee, 249, 251f–252f volar, wrist, 119 knee, 244–249 ganglion, 249, 251f–252f lower leg, 335–337, 336f–337f paralabral aspiration, 367–368, 368f glenoid labrum, 61–63, 63f suprascapular vein dilation and, 63f parameniscal, 234, 234f D De Quervain disease, 136–140, 139f De Quervain tenosynovitis, 358–361, 361f Developmental dysplasia, of hip, 210–211, 211e Diabetic muscle infarction, 204, 205f pathology, 2e17, 2e18f Doppler color, 1e12, 1e12f–1e13f power, 1e12, 1e14f Doppler effect, 1e12 Dorsal ganglion cysts, 123 Dorsal joint recesses, 121–123 Dorsal tendons, 121–123 evaluation finger, 125–126, 128f–129f wrist, 121–124, 122f–124f Double contour sign, 235–236 Dupuytren contracture, 159, 160f Dynamic capability, 1e12–1e13 Dynamic imaging, 1e12–1e14 Dysplasia in children, 180–181, 180e–181e developmental, of hip, 210–211, 211e E Elastofibroma, shoulder, 69, 71f Elbow anatomy, 72–73, 73f–74f bursal abnormalities, 85–93, 92f–93f epitrochlear lymph node, 108–109, 108f–109f intra-articular fibroma, 91e joint abnormalities, 85–93, 87e, 87f–90f joint procedures, 345, 349f ligament abnormalities, 99–101, 100f–101f muscle abnormalities, 93–99 olecranon bursa, 90–93, 92f–93f Elbow (Continued) peripheral nerve abnormalities, 101–108 median nerve, 102–105, 105f radial nerve, 105–107, 106f– 107f sheath tumors, 108, 108f ulnar nerve, 101–102, 102f–105f spiral groove syndrome, 105–107 synovial proliferative disorders, 85–90 tendon abnormalities, 93–99 biceps brachii, 93–96, 94f–96f common extensor tendon, 97–99, 98f–99f common flexor tendon, 97–99, 98f–99f triceps brachii, 96–97, 96f–97f ultrasound, 72–109 anterior evaluation of, 75–78, 75f–80f examination technique, 73–85, 75t general comments on, 73–75 lateral evaluation of, 82–85, 83f–84f medial evaluation of, 78–82, 80f–82f posterior evaluation of, 85, 85f–86f ultrasound examination checklist, 370t ultrasound report, 109e Epitrochlear lymph node, 108–109, 108f–109f Extended field of view, 1e10–1e11, 1e11f Extensor tendon abnormalities, 97–99, 98f–99f F Finger, ultrasound examination checklist, 370t Finger evaluation, 124–129 dorsal, 125–126, 128f–129f ligaments, 126–129, 129f volar, 124–125, 126f–127f Flexor carpi radialis tendon, 119 Flexor digitorum tendons, 116–119 Flexor tendon abnormalities, 97–99, 98f–99f Foot anatomy, 257–264 ligamentous, 263–264 muscle, 257–263 tendon, 257–263 bursal abnormalities, 279–293, 291f, 293f adventitious, 291–293, 292f cysts, 335–337, 336f–337f ganglion, 335–336, 336f forefoot ultrasound evaluation, 278–279, 280f fractures, 327–332, 331f–332f Haglund syndrome, 291, 292f heel ultrasound, posterior evaluation, 275–278, 277f–278f inflammatory arthritis gout, 287–289, 288f–290f â•… Index Foot (Continued) psoriatic arthritis, 289–291, 290f rheumatoid arthritis, 285–287, 285f–288f intermetatarsal bursae, 291–293 joint abnormalities, 279–293 joint effusion, 279–285, 281f, 283f joint procedures, 352–355, 354f knot of Henry, 259–260, 267–268, 270f ligaments abnormalities, 323–327, 329f–331f anatomy, 263–264 Bassett, 263–264 masses, 335–337, 336f–337f giant cell tumor, 335, 336f muscle abnormalities, 293–323 osseous anatomy, 257, 258f–263f peripheral nerve abnormalities, 332–335, 333f–335f plantar muscle abnormalities, 321–323, 322f–324f tendon abnormalities, 321–323, 322f–324f synovial hypertrophy, 279–285, 282f, 284f–285f tendon abnormalities, 293–323 ultrasound, 257–337 examination technique for, 264–279, 264t general comments on, 264 Forefoot ultrasound evaluation, 278–279, 280f ultrasound examination checklist, 371t Fractures ankle, 327–332, 331f–332f foot, 327–332, 331f–332f greater tuberosity, 63–64, 64f lower leg, 327–332, 331f–332f Maisonneuve, 323, 328f nonunion, 2e7–2e8, 2e8f pathology, 2e6–2e7, 2e7f Fusion imaging, 1e11 G Ganglion cysts aspiration, 367–368, 367f–368f dorsal, wrist, 123 foot and ankle, 335–336, 336f hand and wrist, 154–157, 156f–157f knee, 249, 251f–252f pathology, 2e28–2e29, 2e29f volar, wrist, 119 Geyser sign, 64–66, 66f Giant cell tumor foot and ankle, 335, 336f tendon sheath, 158, 158f–159f Glenohumeral joint, 57–61 recesses, 57–61, 60f–61f Glenoid labrum, 61–63 paralabral cyst, 61–63, 63f posterior, shoulder ultrasound examination technique and, 16–18, 18f–19f tear, 61–62, 62f Glomus tumor, 159–160, 161f Gluteus medius, 195–200, 199f calcific tendinosis, 203–204, 204f Gout ankle, 287–289, 288f–290f foot, 287–289, 288f–290f hand, 134–135, 135f–136f knee, 240–242, 241f–242f lower leg, 287–289, 288f–290f pathology, 2e15, 2e15f–2e16f wrist, 134–135, 135f–136f Greater trochanteric bursae procedures, 356–357, 357f Greater tuberosity, 63–64 facets, 3–5, 5f fracture, 63–64, 64f Guyon canal, 119–121, 120f–121f H Haglund syndrome, 291, 292f Hamstrings tendinosis, 200, 200f tendon tears, 200, 201f Hand adductor pollicis aponeurosis, 150–151, 151f anatomy, 110–115, 111f–115f angioleiomyoma, 158, 159f boxer knuckle, 140, 142f de Quervain disease, 136–140, 139f Dupuytren contracture, 159, 160f finger evaluation, 124–129 dorsal, 125–126, 128f–129f ligaments, 126–129, 129f volar, 124–125, 126f–127f ganglion cyst, 154–157, 156f–157f giant cell tumor of tendon sheath, 158, 158f–159f glomus tumor, 159–160, 161f Guyon canal, 119–121, 120f– 121f intersection syndrome, 143–144 joint abnormalities, 129–135 bone proliferation, 134, 134f–135f erosions, 133–134, 133f–134f gout, 134–135, 135f–136f joint effusion, 130f joint procedures, 345, 349f–350f joint recesses dorsal, 121–123 volar, 116–119 ligament abnormalities, 148–153 ligament injuries, 151–153, 152f–154f scapholunate, 148–149, 149f ulnar, 149–151, 150f–151f masses, 158–161 miscellaneous, 160–161 muscle abnormalities, 135–144, 142f, 144f–145f osseous abnormalities, 148–153 osseous injury, 153, 154f peripheral nerve abnormalities, 144–148 carpal tunnel syndrome, 144–146, 145f–147f radial nerve compression, 148, 148f 375 Hand (Continued) transection neuromas, 148, 148e, 149f ulnar tunnel syndrome, 147–148, 148f pulley injury, 143, 143f–144f pulp, 115 synovial hypertrophy, 129–131, 131f–132f tendinosis, 140, 140f–141f tendon abnormalities, 135–144, 142f, 144f–145f tendon tears, 140, 141f–142f tenosynovitis, 135–136, 136f–138f ultrasound, 110–161 examination technique, 115–129, 116t general comments on, 116 ultrasound examination checklist, 370t Heel ultrasound, posterior evaluation, 275–278, 277f–278f Hemangiomas, 2e26 Hematoma, quadriceps, 195, 198f Hemorrhage, 2e2f thigh, 200, 202f Hernias, hip and thigh, 192e, 209–210, 209e High ankle sprain, 323 Hip adductor insertion avulsion syndrome, 193–195, 196f anatomy, 162–165, 163f–166f bursal abnormalities, 181–192, 189f–191f calcific tendinosis, 203–204, 204f–205f dysplasia child evaluation for, 180–181, 180e–181e developmental, 210–211, 211e inguinal region evaluation, 175–176, 176e joint abnormalities, 181–192 joint effusion, 181–185, 183f–185f joint procedures, 348, 351f labrum abnormalities, 185–187, 186f–187f miscellaneous conditions, 206–211 hernias, 192e, 209–210, 209e inguinal lymph node, 206–207, 207f–208f Morel-Lavallée lesion, 206, 207f soft tissue masses, 207–209, 209e, 209f muscle abnormalities, 193–205 muscle injury, 193–200, 194f–195f peripheral nerve abnormalities, 205–206, 206f postsurgical, 188–192, 191f–194f proximal femur abnormalities, 185–187, 187f–188f, 192e snapping hip syndrome, 200–203, 203f–204f synovial hypertrophy, 181–185, 185f–186f tendinopathy, 193 tendon abnormalities, 193–205 tendon injury, 193–200 ultrasound, 162–211 376 Index Hip (Continued) examination technique, 166–181, 166t general comments on, 166– 167 ultrasound evaluation anterior, 167–171, 167f–171f in children, 180–181 lateral, 171–174, 172f–173f posterior, 174–175, 174f–175f ultrasound examination checklist, 371t ultrasound report, 211e I Iliopsoas bursa, procedures, 356, 356f tendon sheath procedures, 361, 362f Impingement, screw, 2e6, 2e6f Impingement syndrome, 40–42, 43f–44f Increased through-transmission artifact, 1e8–1e9, 1e8f–1e9f Infection acromioclavicular joint, 67f pathology, 2e8–2e12, 2e9f–2e10f, 2e11f–2e12f sternoclavicular joint, 68f Inflammatory arthritis ankle, foot and lower leg, 285–291 gout, 287–289, 288f–290f ankle, 287–289, 288f–290f foot, 287–289, 288f–290f hand, 134–135, 135f–136f knee, 240–242, 241f–242f lower leg, 287–289, 288f–290f wrist, 134–135, 135f–136f psoriatic arthritis, 289–291, 290f rheumatoid arthritis, 285–287, 285f–288f Infraspinatus tendon shoulder ultrasound examination technique and, 8–18, 10f–15f, 18f–19f supraspinatus-infraspinatus junction, 46–47, 47f tears, 32–33, 32f tendinosis, 32–33, 32f–33f Inguinal region evaluation, 175–176, 176e lymph node, hip and thigh, 206–207, 207f–208f superficial inguinal ring, 164–165 Intermetatarsal bursae, 291–293 Interosseous membranes, 275, 276f Intersection syndrome, 143–144 Interventional techniques, 338–369 bursal procedures, 355–357, 359f Baker cyst, 357, 358f–359f greater trochanteric, 356–357, 357f iliopsoas, 356, 356f subacromial-subdeltoid, 355–356, 355f–356f joint procedures, 344–355 acromioclavicular, 346f–347f ankle, 352–355, 353f–354f elbow, 345, 349f foot, 352–355, 354f Interventional techniques (Continued) hand, 345, 349f–350f hip, 348, 351f joint recess for, 345 knee, 348–352, 352f pelvis, 348, 351f shoulder, 345, 346f–348f wrist, 345, 349f–350f miscellaneous procedures, 367–369 biopsy, 368–369, 369f cyst aspiration, 367–368, 367f–368f peripheral nerve block, 368 technical considerations, 339–344 approach and, 340–341 ergonomics and, 340–341 needle guidance overview and, 339–340, 339f–340f needle selection and, 340–341 needle visualization and, 343–344, 343f–344f site prepping for, 341–343, 342f transducer selection and, 340–341 tendon procedures, 362–367 calcified tendinosis lavage and aspiration, 362–364, 363f–364f platelet-rich plasma injection, 366–367, 367f tendon fenestration, 364–366, 365f–366f whole blood injection, 366–367 tendon sheath procedures, 357–362 biceps brachii long head, 358, 360f de Quervain tenosynovitis, 358–361, 361f iliopsoas, 361, 362f piriformis, 361–362, 362f ultrasound report, 369e Intrasubstance tear, rotator cuff ultrasound and, 48, 49f J Joint abnormalities ankle, 279–293 elbow, 85–93, 87e, 87f–90f foot, 279–293 hand, 129–135 bone proliferation, 134, 134f–135f erosions, 133–134, 133f–134f gout, 134–135, 135f–136f hip, 181–192 knee, 227–236 cartilage abnormalities, 231–236, 233f, 235f–236f joint effusion, 227–231 synovial hypertrophy, 227–231 lower leg, 279–293 thigh, 181–192 wrist, 129–135 bone proliferation, 134, 134f–135f erosions, 133–134, 133f–134f gout, 134–135, 135f–136f Joint effusion ankle, 279–285, 281f, 283f biceps tendon, 49–51, 50f–51f Joint effusion (Continued) foot, 279–285, 281f, 283f hand, 130f hip, 181–185, 183f–185f knee, 227–231, 228f–230f lower leg, 279–285, 281f, 283f supraspinatus tendon, 31, 31f thigh, 181–185, 183f–185f wrist, 130f Joint erosions, hand and wrist, 133–134, 133f–134f Joint procedures, 344–355 acromioclavicular, 346f–347f ankle, 352–355, 353f–354f elbow, 345, 349f foot, 352–355, 354f hand, 345, 349f–350f hip, 348, 351f joint recess for, 345 knee, 348–352, 352f metacarpophalangeal, 345, 350f pelvis, 348, 351f shoulder, 345, 346f–348f wrist, 345, 349f–350f Joint recesses dorsal, 121–123 glenohumeral, 57–61, 60f–61f for joint interventional procedures, 345 volar, 116–119 Jumper’s knee, 237–240, 238f–239f K Knee ACL reconstruction, 237–240, 240f anatomy, 212–215, 213f–214f Baker cyst, 212, 223–224, 244–247, 246f–247f bone abnormalities, 242–244 bursae, 244–249, 248f–251f cysts, 244–249 ganglion, 249 parameniscal, 234, 234f double contour sign, 235–236 gout, 240–242, 241f–242f intra-articular bodies, 229–231, 232f joint abnormalities, 227–236 cartilage abnormalities, 231–236, 233f, 235f–236f joint effusion, 227–231, 228f–230f synovial hypertrophy, 227–231, 230f–231f joint procedures, 348–352, 352f jumper’s knee, 237–240, 238f–239f ligament abnormalities, 242–244 cruciate, 244, 244f–245f lateral collateral, 242–244, 243f medial collateral, 242, 243f ligaments, 212–215 meniscofemoral, 218–220 meniscotibial, 218–220 popliteofibular, 223, 224f meniscal pathology, 234–235, 235f muscle abnormalities, 236–242 osseous injury, 244, 245f patellar clunk syndrome, 229–231, 232f â•… Index Knee (Continued) patellar tendon injury, 237–240, 238f–240f, 239e peripheral nerves, 215 abnormalities, 249–253, 252f–253f quadriceps femoris injury, 236–237, 237f–238f tendinosis, 236–237 tendon injury, 240, 240f–241f patellar, 237–240, 238f–240f, 239e tendons, 215 abnormalities in, 236–242 ultrasound, 212–256 anterior evaluation of, 216–218, 216f–219f examination, 215–227, 215t general comments on, 216 lateral evaluation of, 221–223, 221f–224f medial evaluation of, 218–221, 219f–221f posterior evaluation, 223–227 ultrasound examination checklist, 371t ultrasound report, 256e vascular abnormalities, 253–256, 254f–255f knot of Henry, 259–260, 267–268, 270f L Labrum abnormalities, 185–187, 186f–187f glenoid, 61–63 paralabral cyst, 61–63, 63f posterior, shoulder ultrasound examination technique and, 16–18, 18f–19f tear, 61–62, 62f paralabral cyst aspiration, 367–368, 368f glenoid labrum, 61–63, 63f suprascapular vein dilation and, 63f Lateral collateral ligament abnormalities, 242–244, 243f Lesions See also Masses Morel-Lavallée, 206, 207f Stener, 150–151, 150f–151f Ligament abnormalities ankle, 323–327, 329f–331f lateral, 274, 274f, 315f, 325f–327f collateral lateral, 242–244, 243f medial, 242, 243f elbow, 99–101, 100f–101f foot, 323–327, 329f–331f hand, 148–153 knee, 242–244 cruciate, 244, 244f–245f lateral collateral, 242–244, 243f medial collateral, 242, 243f lower leg, 323–327, 329f–331f wrist, 148–153 Ligament injuries hand, 151–153, 152f–154f scapholunate, 148–149, 149f ulnar collateral, 149–151, 150f–151f wrist, 151–153, 152f–154f Ligaments ACL, 237–240, 240f ankle Bassett, 263–264 lateral, 274, 274f, 315f, 325f–327f collateral lateral, abnormalities, 242–244, 243f medial, abnormalities, 242, 243f ulnar, injury, 149–151, 150f–151f cruciate, 237–240, 240f finger, 126–129, 129f meniscofemoral, 218–220 meniscotibial, 218–220 popliteofibular, 223, 224f scapholunate, 123, 124f wrist, 123, 124f Lipoma, pathology, 2e23–2e24, 2e23f–2e24f, 2e25f Lisfranc joint, 257 Lower leg ankle, 291–293, 291f, 293f bursal abnormalities, 279–293, 291f, 293f calf muscle abnormalities, 317–321, 319f–322f tendon abnormalities, 317–321, 319f–322f ultrasound evaluation, 278, 279f cysts, 335–337, 336f–337f fractures, 327–332, 331f–332f inflammatory arthritis gout, 287–289, 288f–290f psoriatic arthritis, 289–291, 290f rheumatoid arthritis, 285–287, 285f–288f joint abnormalities, 279–293 joint effusion, 279–285, 281f, 283f ligament abnormalities, 323–327, 329f–331f masses, 335–337, 336f–337f muscle abnormalities, 293–323 anterior, 307–308, 311f peripheral nerve abnormalities, 332–335, 333f–335f synovial hypertrophy, 279–285, 282f, 284f–285f tendon abnormalities, 293–323 anterior, 307–308, 309f–311f posterior, 308–317, 312f–314f repair of, 316–317, 318f tears, 315, 315f–317f tennis leg, 317–318 ultrasound, 257–337 examination technique for, 264–279, 264t general comments on, 264 Lymph nodes biopsy, 368–369, 369f enlargement, shoulder, 68–69, 70f epitrochlear, 108–109, 108f–109f inguinal, hip and thigh, 206–207, 207f–208f soft tissue mass pathology, 2e29, 2e30f Lymphoma, shoulder, 68–69, 70f M Maisonneuve fracture, 323, 328f 377 Masses See also specific masses ankle, 335–337, 336f–337f foot, 335–337, 336f–337f hand, 158–161 miscellaneous, 160–161 lower leg, 335–337, 336f–337f soft tissue, hip and thigh, 207–209, 209e, 209f wrist, 158–161 miscellaneous, 160–161 Medial collateral ligament abnormalities, 242, 243f Median nerve abnormalities, elbow, 102–105, 105f sonographic appearances of normal, 1e6, 1e6f wrist, 116–119 Meniscal pathology, knee, 234–235, 235f Meniscofemoral ligaments, 218–220 Meniscotibial ligaments, 218–220 Metacarpophalangeal joint procedures, 345, 350f Morel-Lavallée lesion, 2e1–2e5, 2e4f, 206, 207f Morton neuroma, 332–333, 333f–334f Muscle, sonographic appearances of normal, 1e5–1e6, 1e5f Muscle abnormalities ankle, 293–323 anterior, 307–308, 311f lateral, 300–306, 301f medial, 293–300, 294f–296f calf, 317–321, 319f–322f elbow, 93–99 foot, 293–323 plantar, 321–323, 322f–324f hand, 135–144, 142f, 144f–145f hip, 193–205 knee, 236–242 lower leg, 293–323 anterior, 307–308, 311f thigh, 193–205 wrist, 135–144, 142f, 144f–145f Muscle injury chronic, 2e6 direct impact, 2e5–2e6, 2e5f hip, 193–200, 194f–195f pathology, 2e1–2e6, 2e1f–2e3f, 2e4f–2e5f, 2e6f penetrating, 2e6 thigh, 193–200, 194f–195f Musculotendinous junction, rotator cuff ultrasound and, 46 Myositis, pathology, 2e17, 2e17f Myositis ossificans, 2e1–2e5, 2e4f N Needle guidance, 339–340, 339f–340f needle entry site, 340, 341f needle orientation and, 344, 344f needle selection, 340–341 needle visualization and, 343–344, 343f–344f overview, 339–340, 339f–340f site prepping for, 341–343, 342f tendon fenestration, 364–366 tendon sheath procedure, 358, 360f 378 Index Neuromas amputation, shoulder, 69, 70f Morton, 332–333, 333f–334f transection, hand and wrist, 148, 148e, 149f Normal structures rotator cuff, misrepresentation of, 45–47 sonographic appearances, 1e5–1e6 O Olecranon bursa, 90–93, 92f–93f Osseous abnormalities, hand and wrist, 148–153 Osseous anatomy, 257, 258f–263f interosseous membrane, 275, 276f Osseous injury hand and wrist, 153, 154f knee, 244, 245f Osteoarthritis, pathology, 2e15–2e16, 2e16f P Palmar plate, 111–112 Paralabral cyst aspiration, 367–368, 368f glenoid labrum, 61–63, 63f suprascapular vein dilation and, 63f Parameniscal cyst, 234, 234f Patellar clunk syndrome, 229–231, 232f Patellar tendon injury, 237–240, 238f–240f, 239e Sinding-Larsen-Johansson disease, 237–240 Pectoralis major, 64, 65f Pelvis, joint procedures, 348, 351f Peripheral nerve, sheath tumors, pathology, 2e25, 2e26f–2e27f Peripheral nerve abnormalities ankle, 332–335, 333f–335f elbow, 101–108 median nerve, 102–105, 105f radial nerve, 105–107, 106f–107f sheath tumors, 108, 108f ulnar nerve, 101–102, 102f–105f foot, 332–335, 333f–335f hand and wrist, 144–148 carpal tunnel syndrome, 144–146, 145f–147f radial nerve compression, 148, 148f transection neuromas, 148, 148e, 149f ulnar tunnel syndrome, 147–148, 148f hip, 205–206, 206f knee, 249–253, 252f–253f lower leg, 332–335, 333f–335f thigh, 205–206, 206f Peripheral nerve entrapment, pathology, 2e21–2e23 Peripheral nerves block, 368 knee, 215 tendon sheath tumors, 108, 108f Peroneal tendons, 271–274, 272f–273f abnormalities, 302–304, 303f–304f Peroneal tubercle, 271–272, 272f Peroneus brevis muscle, low lying belly of, 269–271, 302–304, 304f Peroneus quartus, 260–262 Piriformis, tendon sheath procedures, 361–362, 362f Platelet-rich plasma injection, 366–367, 367f Popliteofibular ligament, 223, 224f Posterior acoustic enhancement, 1e8–1e9 Posterior reverberation, 1e9 Posterolateral plica, 83 Posttraumatic osteolysis, 64–66 Proximal femur abnormalities, 185–187, 187f–188f, 192e Pseudohypertrophy of tensor fasciae latae, 204–205, 206f Psoriatic arthritis, 289–291, 290f pathology, 2e14–2e15, 2e14f Pulley injury, hand and wrist, 143, 143f–144f Quadriceps femoris, injury, 236–237, 237f–238f hematoma, 195, 198f Rotator cuff (Continued) improper shoulder positioning and, 44, 45f intrasubstance tear and, 48, 49f misinterpretation of musculotendinous junction in, 46, 46f misinterpretation of normal structures in, 45–47 misinterpretation of pathology, 47–49 misinterpretation of rotator interval in, 45–46 misinterpretation of supraspinatus-infraspinatus junction in, 46–47, 47f pitfalls in, 44–49 rim-rent tear and, 48, 49f subacromial-subdeltoid bursa simulating tendon, 47–48, 47f–48f supraspinatus tendon evaluation and, 44, 45f tendinosis and, 48–49, 48t tendon tear and, 48–49, 48t Rotator interval, 3–5 rotator cuff ultrasound and, 45–46 R S Q Radial artery, wrist, 119 Radial nerve abnormalities, elbow, 105–107, 106f–107f compression, 148, 148f Rectus femoris calcific tendinosis, 203–204, 205f injuries, 195, 196f–198f Rheumatoid arthritis, 285–287, 285f–288f pathology, 2e12–2e14, 2e13f–2e14f Rim-rent tear rotator cuff ultrasound and, 48, 49f supraspinatus tendon, 21–22 Ring-down artifact, 1e9, 1e9f Rotator cable, 15, 15f Rotator cuff See also Shoulder abnormalities, 18–44 infraspinatus tears and tendinosis, 32–33 subscapularis tears and tendinosis, 33, 33f–34f supraspinatus tears and tendinosis, 18–32, 20f–21f atrophy, 33–36, 35f–36f adhesive capsulitis and, 42–44, 44f calcific tendinosis and, 38–40 impingement syndrome and, 40–42, 43f–44f postoperative shoulder and, 36–38 teres minor, 35–36 greater tuberosity facet, 3–5, 5f rotator cable, 15, 15f rotator interval and, 3–5, 45–46 tendons, 3–5, 4f ultrasound errors in scanning technique for, 44 imaging too distally and, 44 Scaphoid, wrist, 119 Scapholunate ligament, 123, 124f injury, 148–149, 149f Shadowing, 1e7–1e8, 1e8f Shoulder amputation neuroma, 69, 70f anatomy, 3–71 Crass position, 8–9, 12f elastofibroma, 69, 71f glenohumeral joint, 57–61 recesses, 57–61, 60f–61f glenoid labrum, 61–63 paralabral cyst, 61–63, 63f posterior, shoulder ultrasound examination technique and, 16–18, 18f–19f tear, 61–62, 62f greater tuberosity, 63–64 facets, 3–5, 5f fracture, 63–64, 64f joint procedures, 345, 346f–348f lymph node enlargement, 68–69, 70f lymphoma, 68–69, 70f miscellaneous disorders, 68–71 paralabral cyst glenoid labrum, 61–63, 63f suprascapular vein dilation and, 63f pectoralis major, 64, 65f postoperative, 36–38 rotator cuff ultrasound and positioning of, 44, 45f slipping rib syndrome, 69–71, 71f sternalis muscle, 71e sternoclavicular joint dislocation, 66–68, 68f–69f infection, 68f ultrasound examination checklist, 370t â•… Index Shoulder (Continued) ultrasound examination technique, 5–18, 5t general comments on, patient positioning, 5e position no 1: long head of biceps brachii tendon and, 5–6, 6f–7f position no 2: subscapularis and biceps tendon dislocation, 7–8, 8f position no 3: supraspinatus and infraspinatus, 8–15, 10f–15f position no 4: acromioclavicular joint, subacromial-subdeltoid bursa, and dynamic evaluation, 15–16 position no 5: infraspinatus, teres minor, and posterior glenoid labrum, 16–18, 18f–19f ultrasound report, 71e xiphoid process, 69–71, 71f Sinding-Larsen-Johansson disease, 237–240 Sinus tarsi, 257 Slipping rib syndrome, 69–71, 71f Snapping hip syndrome, 200–203, 203f–204f Soft tissue foreign bodies, pathology, 2e17–2e21, 2e18f–2e19f, 2e20f–2e21f, 2e22f Soft tissue masses biopsy, 368–369, 369f hip and thigh, 207–209, 209e, 209f pathology, 2e23–2e33 ganglion cysts, 2e28–2e29, 2e29f lipoma, 2e23–2e24, 2e23f–2e24f, 2e25f lymph nodes, 2e29, 2e30f peripheral nerve sheath tumors, 2e25, 2e26f–2e27f vascular anomalies, 2e26–2e28, 2e27f–2e28f Soft tissue tumors, malignant, 147e, 2e29–2e33, 2e31f–2e32f, 2e33f–2e34f Spatial compound sonography, 1e10, 1e10f Spiral groove syndrome, 105–107 Stener lesion, 150–151, 150f–151f Sternalis muscle, 71e Sternoclavicular joint dislocation, 66–68, 68f–69f infection, 68f Subacromial-subdeltoid bursa, 56–57, 57f–60f procedures, 355–356, 355f–356f shoulder ultrasound examination technique, 15–16, 16f–17f simulating tendon, 47–48, 47f–48f Subscapularis tendon avulsion, 34f dislocation, shoulder ultrasound and, 7–8, 8f–9f tears, 33, 33f–34f tendinosis, 33, 33f–34f Superficial inguinal ring, 164–165 Suprascapular vein dilation, 63f Supraspinatus tendon See also Shoulder bursal fluid, 31, 32f cartilage interface sign, 32 cortical irregularity, 31 evaluation in long axis of, 9–10 intra-articular portion of, 10–15, 15f joint effusion, 31, 31f shoulder ultrasound examination technique and, 8–15, 10f–15f tears, 18–32 complete or full-width, 18–20 full-thickness, 25–29, 26f–30f general comments on, 18–32, 20f–21f indirect signs of, 30–32 interstitial, 23 intrasubstance, 23, 25f partial thickness, 20–23, 22f–23f partial thickness, bursal-side, 22–23, 23f–24f rim-rent, 21–22 tendinosis, 18–32, 30f general comments on, 18–20 thinning, 30, 30f transducer and evaluation of, 10–15 ultrasound and, 44, 45f Supraspinatus-infraspinatus junction, rotator cuff ultrasound and, 46–47, 47f Surgery hip after, 188–192, 191f–194f shoulder after, 36–38, 37f–40f Synovial biopsy, 344–345 Synovial hypertrophy ankle, 279–285, 282f, 284f–285f foot, 279–285, 282f, 284f–285f hand and wrist, 129–131, 131f–132f hip and thigh, 181–185, 185f–186f knee, 227–231, 230f–231f lower leg, 279–285, 282f, 284f–285f Synovial proliferative disorders, 85–90 T Tendinitis, 2e6 Tendinopathy, hip and thigh, 193 Tendinosis, 193 Achilles, 308–315, 312f–314f ankle, 295, 297f lateral, 301–302, 301f–302f biceps, 51–52, 52f, 54f calcific, 38–40, 41f–42f lavage and aspiration of, 362–364, 363f–364f hamstrings, 200, 200f hand and wrist, 140, 140f–141f infraspinatus, 32–33, 32f–33f knee, 236–237 rotator cuff ultrasound and, 48–49, 48t subscapularis, 33, 33f–34f supraspinatus, 18–32, 30f general comments on, 18–20 thigh, 195–200, 199f–200f, 202f Tendon abnormalities See also specific abnormalities Achilles, 317, 318f–319f ankle, 293–323 anterior, 307–308, 309f–311f 379 Tendon abnormalities (Continued) lateral, 300–306, 301f, 303f medial, 293–300, 294f–295f, 300f posterior, 308–317, 312f–314f repair of, 316–317, 318f biceps brachii, 93–96, 94f–96f calf, 317–321, 319f–322f elbow, 93–99 biceps brachii, 93–96, 94f–96f common extensor tendon, 97–99, 98f–99f common flexor tendon, 97–99, 98f–99f triceps brachii, 96–97, 96f–97f extensor, 97–99, 98f–99f flexor, 97–99, 98f–99f foot, 293–323 plantar, 321–323, 322f–324f hand, 135–144, 142f, 144f–145f hip, 193–205 knee, 236–242 lower leg, 293–323 anterior, 307–308, 309f–311f posterior, 308–317, 312f–314f repair of, 316–317, 318f peroneal, 302–304, 303f–304f plantar foot, 321–323, 322f–324f thigh, 193–205 triceps brachii, 96–97, 96f–97f wrist, 135–144, 142f, 144f–145f Tendon fenestration, 364–366, 365f–366f needle guidance, 364–366 Tendon injury chronic, 2e6 hip, 193–200 knee, 240, 240f–241f patellar, 237–240, 238f–240f, 239e pathology, 2e1–2e6 penetrating, 2e6 thigh, 193–200 Tendon procedures, 362–367 calcified tendinosis lavage and aspiration, 362–364, 363f–364f platelet-rich plasma injection, 366–367, 367f tendon fenestration, 364–366, 365f–366f whole blood injection, 366–367 Tendon sheath procedures, 357–362 biceps brachii long head, 358, 360f de Quervain tenosynovitis, 358–361, 361f iliopsoas, 361, 362f needle guidance, 358, 360f piriformis, 361–362, 362f Tendon sheath tumors giant cell, 158, 158f–159f peripheral nerve, elbow, 108, 108f Tendon tears Achilles, 317e full-thickness, 316–317, 316f–317f partial-thickness, 315, 315f ankle, 315, 315f–317f biceps, 51–52, 52f–53f full-thickness Achilles, 316–317, 316f–317f ankle, 298–300, 299f–300f supraspinatus, 25–29, 26f–30f 380 Index Tendon tears (Continued) glenoid labrum, 61–62, 62f hamstring, 200, 201f hand, 140, 141f–142f infraspinatus, 32–33, 32f intrasubstance, rotator cuff ultrasound and, 48, 49f lower leg, 315, 315f–317f partial-thickness Achilles, 315, 315f ankle, 295–298, 297f–299f supraspinatus, 22–23, 22f–24f rim-rent rotator cuff ultrasound and, 48, 49f supraspinatus, 21–22 rotator cuff ultrasound and, 48–49, 48t subscapularis, 33, 33f–34f supraspinatus, 18–32 complete or full-width, 18–20 full-thickness, 25–29, 26f–30f general comments on, 18–32, 20f–21f indirect signs of, 30–32 interstitial, 23 intrasubstance, 23, 25f partial thickness, 20–23, 22f–23f partial thickness, bursal-side, 22–23, 23f–24f rim-rent, 21–22 thigh, 195–200, 199f, 201f–202f wrist, 140, 141f–142f Tennis leg, 317–318 Tenosynovitis biceps tendon, 49–51, 50f de Quervain, 358–361, 361f hand and wrist, 135–136, 136f–138f Tensor fasciae latae, pseudohypertrophy of, 204–205, 206f Teres minor atrophy, 35–36 shoulder ultrasound examination technique, 16–18, 18f–19f Thigh adductor insertion avulsion syndrome, 193–195, 196f anatomy, 162–165, 163f–166f bursal abnormalities, 181–192, 189f–191f diabetic muscle infarction, 204, 205f gluteus medius, 195–200, 199f calcific tendinosis, 203–204, 204f hamstrings tendinosis, 200, 200f tendon tears, 200, 201f hemorrhage, 200, 202f joint abnormalities, 181–192 joint effusion, 181–185, 183f–185f labrum abnormalities, 185–187 miscellaneous conditions, 206–211 hernias, 192e, 209–210, 209e inguinal lymph node, 206–207, 207f–208f Morel-Lavallée lesion, 206, 207f soft tissue masses, 207–209, 209e, 209f muscle abnormalities, 193–205 Thigh (Continued) muscle injury, 193–200, 194f–195f peripheral nerve abnormalities, 205–206, 206f proximal femur abnormalities, 185–187, 187f–188f, 192e pseudohypertrophy of tensor fasciae latae, 204–205, 206f quadriceps, hematoma, 195, 198f rectus femoris calcific tendinosis, 203–204, 205f injuries, 195, 196f–198f splints, 193–195, 196f synovial hypertrophy, 181–185, 185f–186f tendinopathy, 193 tendinosis, 195–200, 199f–200f, 202f tendon abnormalities, 193–205 tendon injury, 193–200 tendon tears, 195–200, 199f, 201f–202f ultrasound, 162–211 examination technique, 166–181, 166t general comments on, 166–167 ultrasound evaluation anterior, 176, 177f–178f medial, 176–178, 179f posterior, 178–180, 180f–182f ultrasound examination checklist, 371t Three-dimensional ultrasound, 1e11, 1e11f Tissue harmonic imaging, 1e10, 1e10f–1e11f Transducers, 1e1, 1e1f heel-toe movements, 1e2, 1e3f scanning technique, 1e2–1e3, 1e2f selection, 340–341 image optimization and, 1e4–1e5 sweep movements, 1e2 toggle movements, 1e2, 1e3f translate movements, 1e2 Transection neuromas, hand and wrist, 148, 148e, 149f Triangular fibrocartilage, 110 complex, wrist, 124, 125f Triceps brachii tendon abnormalities, 96–97, 96f–97f Tumors See also Masses giant cell foot and ankle, 335, 336f tendon sheath, 158, 158f–159f glomus, 159–160, 161f tendon sheath giant cell, 158, 158f–159f peripheral nerve, elbow, 108, 108f U Ulnar artery aneurysm, 147e hypothenar hammer syndrome, 147e wrist, 119–121, 120f–121f Ulnar collateral ligament injury, 149–151, 150f–151f Ulnar nerve abnormalities, elbow, 101–102, 102f–105f wrist, 119–121, 120f–121f Ulnar tunnel syndrome, 147–148, 148f Ulnar vein, wrist, 119–121, 120f–121f Ultrasound ankle, 257–337 anterior evaluation, 264–266, 265f–266f general comments on, 264 lateral evaluation, 269–275, 271f–272f, 275f medial evaluation, 266–269, 267f–271f posterior evaluation, 275–278 calf, 278, 279f Doppler color, 1e12, 1e12f–1e13f duplex, 1e12 power, 1e12, 1e14f pulsed-wave, 1e12 dynamic imaging, 1e12–1e14 elbow, 72–109 anterior evaluation of, 75–78, 75f–80f general comments on, 73–75 lateral evaluation of, 82–85, 83f–84f medial evaluation of, 78–82, 80f–82f posterior evaluation of, 85, 85f–86f equipment considerations, 1e1–1e2 foot, 257–337 forefoot, 278–279, 280f hand, 110–161 general comments on, 116 heel, posterior evaluation, 275–278, 277f–278f hip, 162–211 anterior evaluation, 167–171, 167f–171f general comments on, 166–167 in children, 180–181 lateral evaluation, 171–174, 172f–173f posterior evaluation, 174–175, 174f–175f image anechoic, 1e5 appearance, 1e3–1e5, 1e3f formation, 1e1–1e2 hyperechoic, 1e5 hypoechoic, 1e5 isoechoic, 1e5 optimizing, 1e4–1e5, 1e4f sound beam depth and, 1e4–1e5, 1e4f transducer selection and, 1e4–1e5 interventional techniques, 338–369 bursal procedures, 355–357, 359f joint procedures, 344–355 miscellaneous procedures, 367–369 technical considerations, 339–344 tendon procedures, 362–367 tendon sheath procedures, 357–362 â•… Index Ultrasound (Continued) knee, 212–256 anterior evaluation of, 216–218, 216f–219f examination, 215–227, 215t general comments on, 216 lateral evaluation of, 221–223, 221f–224f medial evaluation of, 218–221, 219f–221f posterior evaluation of, 223–227, 225f–227f lower leg, 257–337 general comments on, 264 rotator cuff errors in scanning technique for, 44 imaging too distally and, 44 improper shoulder positioning and, 44, 45f intrasubstance tear and, 48, 49f misinterpretation of musculotendinous junction in, 46, 46f misinterpretation of normal structures in, 45–47 misinterpretation of pathology, 47–49 misinterpretation of rotator interval in, 45–46 misinterpretation of supraspinatus-infraspinatus junction in, 46–47, 47f pitfalls in, 44–49 rim-rent tear and, 48, 49f subacromial-subdeltoid bursa simulating tendon, 47–48, 47f–48f supraspinatus tendon evaluation and, 44, 45f tendinosis and, 48–49, 48t tendon tear and, 48–49, 48t scanning technique, 1e2–1e3, 1e2f ergonomics and, 1e2–1e3 sonographic artifacts, 1e6–1e9 anisotropy, 1e6–1e7, 1e7f–1e8f beam-width, 1e9 increased through-transmission, 1e8–1e9, 1e8f–1e9f posterior acoustic enhancement, 1e8–1e9 posterior reverberation, 1e9 ring-down, 1e9, 1e9f shadowing, 1e7–1e8, 1e8f techniques, miscellaneous, 1e10–1e11 elastography, 1e11, 1e12f extended field of view, 1e10– 1e11, 1e11f fusion imaging, 1e11 spatial compound sonography, 1e10, 1e10f three-dimensional, 1e11, 1e11f tissue harmonic imaging, 1e10, 1e10f–1e11f thigh, 162–211 anterior evaluation, 176, 177f–178f general comments on, 166–167 Ultrasound (Continued) medial evaluation, 176–178, 179f posterior evaluation, 178–180, 180f–182f units, 1e1–1e2 wrist, 110–161 general comments on, 116 volar evaluation, 116–121, 117f–120f Ultrasound elastography, 1e11, 1e12f shear-wave, 1e11 Ultrasound examination checklists, 370–371 ankle, 371t calf, 371t elbow, 370t finger, 370t forefoot, 371t hand, 370t hip, 371t knee, 371t shoulder, 370t thigh, 371t wrist, 370t Ultrasound examination technique ankle, 264–279, 264t elbow, 73–85, 75t foot, 264–279, 264t hand, 115–129, 116t hip, 166–181, 166t lower leg, 264–279, 264t shoulder, 5–18, 5t general comments on, patient positioning, 5e position no 1: long head of biceps brachii tendon and, 5–6, 6f–7f position no 2: subscapularis and biceps tendon dislocation, 7–8, 8f–9f position no 3: supraspinatus and infraspinatus, 8–15, 10f–15f position no 4: acromioclavicular joint, subacromial-subdeltoid bursa, and dynamic evaluation, 15–16, 16f–17f position no 5: infraspinatus, teres minor, and posterior glenoid labrum, 16–18, 18f–19f thigh, 166–181, 166t wrist, 115–129, 116t Ultrasound guidance, 338 approach, 340–341 biopsy, 368–369, 369f ergonomics, 340–341 needle, 339–340, 339f–340f needle selection, 340–341 needle visualization and, 343–344, 343f–344f site prepping for, 341–343, 342f transducers, 1e1, 1e1f selection, 340–341 Ultrasound report ankle, 337e elbow, 109e hip, 211e interventional, 369e knee, 256e shoulder, 71e wrist, 161e 381 V Vascular abnormalities, knee, 253–256, 254f–255f Vascular anomalies, pathology, 2e26–2e28, 2e27f–2e28f Vastus medialis obliquus, 215 Volar evaluation finger, 124–125, 126f–127f ultrasound, 116–121, 117f–120f Volar ganglion cysts, 119 Volar joint recesses, 116–119 Volar plate, 111–112 W Whole blood injection, 366–367 Wrist adductor pollicis aponeurosis, 150–151, 151f anatomy, 110–115, 111f–115f angioleiomyoma, 158, 159f de Quervain disease, 136–140, 139f dorsal evaluation, 121–124, 122f–124f dorsal ganglion cysts, 123 Dupuytren contracture, 159, 160f flexor carpi radialis tendon, 119 flexor digitorum tendons, 116–119 ganglion cysts, 154–157, 156f–157f dorsal, 123 volar, 119 giant cell tumor of tendon sheath, 158, 158f–159f glomus tumor, 159–160, 161f Guyon canal, 119–121, 120f–121f intersection syndrome, 143–144 joint abnormalities, 129–135 bone proliferation, 134, 134f–135f erosions, 133–134, 133f–134f gout, 134–135, 135f–136f joint effusion, 130f joint procedures, 345, 349f–350f joint recesses dorsal, 121–123 volar, 116–119 ligament abnormalities, 148–153 ligament injuries, 151–153, 152f–154f scapholunate, 148–149, 149f ulnar, 149–151, 150f–151f masses, 158–161 miscellaneous, 160–161 median nerve, 116–119 muscle abnormalities, 135–144, 142f, 144f–145f osseous abnormalities, 148–153 osseous injury, 153, 154f peripheral nerve abnormalities, 144–148 carpal tunnel syndrome, 144–146, 145f–147f radial nerve compression, 148, 148f transection neuromas, 148, 148e, 149f ulnar tunnel syndrome, 147–148, 148f pulley injury, 143, 143f–144f pulp, 115 382 Index Wrist (Continued) radial artery, 119 scaphoid, 119 scapholunate ligament, 123, 124f synovial hypertrophy, 129–131, 131f–132f tendinosis, 140, 140f–141f tendon abnormalities, 135–144, 142f, 144f–145f tendon tears, 140, 141f–142f tenosynovitis, 135–136, 136f–138f Wrist (Continued) triangular fibrocartilage, 110 complex, 124, 125f ulnar artery, vein, and nerve, 119–121, 120f–121f, 147e ultrasound, 110–161 examination technique, 115–129, 116t general comments on, 116 volar evaluation, 116–121, 117f–120f Wrist (Continued) ultrasound examination checklist, 370t ultrasound report, 161e volar ganglion cysts, 119 volar joint recesses, 116–119 volar plate, 111–112 X Xiphoid process, 69–71, 71f ... and angled toward midline (see Fig 6 -22 D) The sciatic nerve is also 180 Fundamentals of Musculoskeletal Ultrasound BF-l ST SM BF-s B A SM C SM SM D E FIGURE 6 -20 ╇ ╇ Posterior thigh evaluation... arthritis (Fig 6- 32) Other synovial proliferative disorders such as pigmented 184 Fundamentals of Musculoskeletal Ultrasound H N A H B H N C FIGURE 6 -27 ╇ ╇ Toxic synovitis Ultrasound images... facet (SP) of the greater trochanter shows (C) an additional insertion site of the gluteus medius (arrows) A, anterior facet, L, lateral facet of the greater trochanter 174 Fundamentals of Musculoskeletal